By Trevor Kletz

This name appears to be like at how humans, in place of expertise and pcs, are arguably the main unreliable issue inside of crops, resulting in risky occasions.

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

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Many hospitalshold weeklymeetings at whichdoctorscan talk candidlyabout their errors. Medical equipment, he says, is rife with latent errors. Cardiac defibrillators, forexample,have no standarddesign. 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.

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.

Two reactors. Nos 4 and 6, on a batch plant were shut down for maintenance. The work on No. 4 was completed and the foreman asked an operator to open the feed valve to No. 4. 11 (page 29), but by mistake pressed the button controlling the inlet valve to No. 6 reactor. The valveopened;flammable gas came out and caught fire. 33, page 250). 11 Arrangement ofoperatingbuttonsfor the inletand exit valves on a groupofbatchreactors We shouldnever tolerate a situationin which such a simple slip has such seriousconsequences.

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