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Table Of Contents

2.4.3 Mistakes
2.4.4 Summary
Latent errors and violations
3.2Latent and active errors
3.2.2Active errors
3.2.3Latent errors
3.3.1 Introduction
3.3.2Definition of a violation
3.3.3Distinction between errors and violations
3.3.4Classification of violations
3.3.5The causes and control of violations
Human reliability analysis
4.2 Measuring human reliability
4.2.1 Introduction
4.2.2 Definitions
4.2.3 Expressing probability values
4.2.4Performance shaping factors
4.2.5Task complexity
4.3Human reliability methods
4.3.1Database methods
4.3.2Expert judgment methods
4.3.3 Conclusion
4.4 Task decomposition
4.4.1 Introduction
4.4.2 Task analysis
4.5 Error identification
4.5.1 Introduction
4.5.2 Taxonomy based methods
4.5.3Knowledge based methods
5.2 Basic probability theory
5.2.1 Introduction
Human error modelling
5.2.2Failure and success probability
5.2.3Probability of two or more independent events
5.2.4Combining human error probabilities using logic gates
5.2.5Fault trees
5.2.6Event trees
5.3 Error recovery
5.3.1 Introduction
5.3.2Error recovery mechanisms
5.3.3Effect of error recovery on error probability
5.4 Error dependency
5.4.1 Introduction
5.4.2Root causes
5.4.3Coupling between errors
5.4.4The importance of error dependency
5.4.5 Dependency modelling
Human error in event sequences
6.2Human reliability event trees
6.2.2Example human reliability analysis event tree
6.2.3Quantification of error probabilities
6.2.4Event tree logic
6.3Scenario analysis
6.3.2Scenario 1:Influence of dependency on outcome F3
6.3.3Scenario 2:Influence of recovery factor in scenario F5
6.4Overview of human error modelling
6.4.2Task analysis
6.4.3 Error identification
6.4.4 Error quantification
6.4.5Human reliability event trees
Organizational and management errors
7.2The Flixborough chemical plant disaster
7.2.2Description of the cyclohexane process
7.2.3Events leading to the accident
7.2.4The accident
7.2.5The public inquiry
7.2.6Alternative event sequence
7.2.7 Epilogue
7.2.8 Conclusions
7.3The capsize of the Herald of Free Enterprise
7.3.1The accident
7.3.2The inquiry
7.3.3 Conclusions
7.4Privatization of the railways
7.4.2Rail safety statistics before and after privatization
7.4.3A brief history of railway safety management
7.4.4The impact of privatization upon safety
7.4.5 Conclusion
Design errors
8.2The fire and explosion at BP Grangemouth
8.2.7 Conclusion
8.3The sinking of the ferry ‘Estonia’
8.3.2The accident
8.3.3The investigation
8.3.4The causes
8.3.5The aftermath
8.3.6 Conclusions
8.4 The Abbeystead explosion
8.4.1 Introduction
8.4.2The accident
8.4.3 The investigation
8.4.4The aftermath
8.4.5 Conclusion
Maintenance errors
9.3The railway accident at Hatfield
9.3.2The accident
9.3.5 Conclusions
9.4The railway accident at Potters Bar
9.4.2Initial investigation – direct causes
9.4.3Later findings – root causes
9.4.4Postscript – the future of rail maintenance?
Active errors in railway operations
10.2Signals passed at danger
10.2.2The accident at Clapham Junction
10.3The train accident at Purley
10.3.2The accident
10.3.3The inquiry
10.4The driver’s automatic warning system
10.4.1System operation
10.4.2A conditioned response
10.4.3The effect of dependency
10.5The Southall and Ladbroke Grove rail accidents
10.5.2The Southall rail accident 1997
10.5.3The Ladbroke Grove accident 1999
10.6Human error analysis of signals passed at danger
10.6.2Causes of SPADs
10.6.3Probability of SPADs
10.6.4Human reliability event tree for SPADs
10.6.5 Conclusion
10.7Driver protection against SPADs
10.7.2Train protection and warning system
10.7.3Automatic train protection (ATP)
10.7.4 Conclusion
Active errors in aviation
11.2The loss of flight KAL007
11.2.2The accident
11.2.3The causes
11.2.4 Conclusions
11.3 The Kegworth accident
11.3.1 Introduction
11.3.2The accident
11.3.3The causes
11.3.4 Conclusion
12.1 Introduction
12.2The Chernobyl accident
12.2.2The Chernobyl reactor
12.2.3Problems with the design
12.2.4The accident
12.2.5The causes
12.2.6 Conclusions
12.3The Airbus A320 crash at Mulhouse
12.3.2The A320 Airbus
12.3.3The accident at Mulhouse
12.3.4 Conclusions
13.1 Introduction
Incident response errors
13.2Fire on Swissair flight SR111
13.2.2The accident
13.2.3The causes
13.2.4 Conclusion
13.3The Channel Tunnel fire
13.3.2Channel Tunnel description
13.3.3The accident
13.3.4The causes and development of the fire
13.3.5The emergency response
13.3.6 Conclusions
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The Blame Machine - Why Human Error Causes Accidents

The Blame Machine - Why Human Error Causes Accidents

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Published by OzzyMiner

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Published by: OzzyMiner on Feb 15, 2011
Copyright:Attribution Non-commercial


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