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

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By Trevor Kletz

This identify seems to be at how humans, rather than know-how and pcs, are arguably the main unreliable issue inside crops, resulting in harmful events.

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Finally, the cause was discovered: every Friday morning a cleaner unplugged the life support systemand pluggedin her floor polisher. When she had finished she replaced the plug on the life-supportsystem but by now the patient was dead. She did not hear any screams above the noise madeby the floor polisher33. 5 (page 213) describes two medical errors involving computers. 9 Railways By considering accidentsdue to humanerror in other industries we can check the validityofour conclusion —thatoccasionalslips and lapsesofattention are inevitable andthat we musteitheracceptthemorchangethework sttuation, but that it is little use exhorting people to take more care.

20. , 1968, Traiiz Wrecks (Bonanza Books, New York, USA). 21 LossPreventionBulletin, 1989. No. 090, page29. 22. As Reference 19, page 126. 23. Hidden, A. 12 (HMSO,London, UK) 24. Evening Gazette (Middlesbrough), 24 and 25 August 1987. 25. Miller, J. USA). 26. Operating Experience Weekly Swnmaiy, 1998, No. 98—52, page 3 (Office of NuclearandFacilitySafety,US Department ofEnergy, Washington, DC, USA). 27. Operating Experience Weekly Summary, 1999, No. 99—17, page 1 (Office of Nuclearand FacilitySafety,US Department ofEnergy, Washington.

When he opened the vent valve, the pressurein the trip fell and the plant was automatically shut down. It took 36 hours to get it back to normal. It would have been of little use telling the artificerto be more careful. To reducethechanceof afurthermistake: • providebetterlabels; • putthetripand alarmfurtherapart; • possiblypaint the tripand alarmdifferentcolours. Thoughnot relevant to this incident, note that the trip and alarmshould be connected to the plant by separate impulse lines to reduce the chance of a commonmode failure: choking of the commonimpulseline.

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