An Engineer’s View of Human Error, Third Edition by Trevor Kletz

By Trevor Kletz

This name seems to be at how humans, rather than know-how and desktops, are arguably the main unreliable issue inside of crops, resulting in risky events.

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Extra info for An Engineer’s View of Human Error, Third Edition

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34 PC(U)tI4TS CAUSED EY SIMPLE SLIPS 'The doctor is often only the linal actor in a chainofeventsthat sethimor her up to fail. Error experts, therefore, believe that it's the process, not the individuals in it, whichrequirescloserexanilnation and correction. In a sense they want to industrialize medicine. Checkson the air-conditioning system and a search for infectionproducedno clues. Finally, the cause was discovered: every Friday morning a cleaner unplugged the life support systemand pluggedin her floor polisher.

To try to clear the choke the operatorsused instrument air. Unfortunately it was at a lowerpressure. As a result water got into the instrument au' linesand the turbinetripped. 1 A pressurizedwaterreactor— simplified This stopped the heat being removed from the radioactive core. The production of fission heat stopped automatically because silver rods which absorb neutrons dropped down into the core and stopped the radioactive fission. However, heatwas still producedby radioactive decay at about 6% of the full load, and this caused the primarywater to boil.

1 Signalmen's eirors A signalman'serror led to Britain'sworstrailwayaccident, atQuintinshill just north of the Scottishborder on the London-Glasgow line, in 1915, when 226 peoplewere killed, most of themsoldiers9. 15 (page 36) shows the layout of the railway lines. Lines to Londonare calledup lines;lines from Londonare calleddown lines. 15 Layoutoflinesat Quintinshill, the sceneofBritain's worst railway accident The two ioop lines were occupied by goods trains and so a slow north-bound passenger train was backed on to the up line in order to let a sleeping car express come past.

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