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| THE BLAME MACHINE: WHY HUMAN ERROR CAUSES ACCIDENTS
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By
R B Whittingham, Qualifications: MInstE., MIGasE., AMIChemE., FSaRS., CEng., Independent Safety Consultant, UK
Description
The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human
errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you
will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale,
you will be able to see where, in the organisational or management systems, failure occurred so that you can avoid them.
The book also
describes the existence of a 'blame culture' in many organisations, which focuses on individual human error whilst ignoring the system
failures that caused it. The book shows how this 'blame culture' has, in the case of a number of past accidents, dominated the accident
enquiry process hampering a proper investigation of the underlying causes.
Suggestions are made about how progress can be made to develop
a more open culture in organisations, both through better understanding of human error by managers and through increased public awareness
of the issues. The book brings together documentary evidence from recent major incidents from all around the world and within the Rail,
Water, Aviation, Shipping, Chemical and Nuclear industries.
Barry Whittingham has worked as a senior manager, design
engineer and consultant for the chemical, nuclear, offshore oil and gas, railway and aviation sectors. He developed a career as a safety
consultant specializing in the human factors aspects of accident causation. He is a member of the Human Factors in Reliability Group,
and a Fellow of the Safety and Reliability Society.
Audience
Students on occupational psychology, occupational health and safety, insurance and risk management courses, especially those on BSc and
MSc Occupational Health and Safety courses.
Safety practitioners in manufacturing and transportation industries; managers; accident investigators
and safety regulators; liability surveyors.
Contents
Preface.
Acknowledgements.
PART 1 - UNDERSTANDING HUMAN ERROR
To err is human:
Defining human error.
Random and systemic errors.
Errors in practice:
Genotypes and phenotypes.
The skill, rule and knowledge taxonomy.
The
generic error modelling system taxonomy.
Latent errors and violations:
Latent and active errors.
Violations.
Human
reliability analysis:
Measuring human reliability.
Human reliability methods.
Task decomposition.
Error identification.
Human
error modelling:
Basic probability theory.
Error recovery.
Error dependency.
Human error in event sequences:
Human reliability event trees.
Scenario analysis.
Overview of human error modelling.
PART 2 - ACCIDENT CASE STUDIES
Organizational and management errors:
The Flixborough chemical plant disaster.
The capsize of the Herald of Free Enterprise.
Privatisation of the railways.
Design errors:
The fire and explosion at BP Grangemouth.
The sinking of the ferry 'Estonia'.
The Abbeystead explosion.
Maintenance errors:
Engine failure on the Royal Flight.
The railway accident at Hatfield.
The railway accident at Potters Bar.
Active errors in railway operations:
Signals passed at danger.
The train accident
at Purley.
The driver's automatic warning system.
The Southall and Ladbroke Grove rail accidents.
Human error analysis of signal passed
at danger.
Driver protection against SPADs.
Active errors in aviation:
The loss of flight KAL007.
The Kegworth accident.
Violations:
The Chernobyl accident.
The Airbus A320 crash at Mulhouse.
Incident response errors:
Fire
on Swissair flight SR111.
The Channel Tunnel fire.
Conclusions:
Human error and blame.
Understanding human error.
Human
error in industry.
Appendix: Train protection systems.
Index.
| Bibliographic details |
Paperback, 288 pages, publication date: DEC-2003
ISBN-13: 978-0-7506-5510-1
ISBN-10: 0-7506-5510-0
Imprint: BUTTERWORTH HEINEMANN
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| Price and Ordering |
Price:
EUR 51.95
USD 67.95
GBP 37.99
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Last update: 4 Sep 2009
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