By Nancy G. Leveson
Engineering has skilled a technological revolution, however the uncomplicated engineering strategies utilized in defense and reliability engineering, created in a less complicated, analog international, have replaced little or no through the years. during this groundbreaking booklet, Nancy Leveson proposes a brand new method of safety--more suited for state-of-the-art complicated, sociotechnical, software-intensive world--based on sleek structures pondering and platforms idea. Revisiting and updating principles pioneered by way of Fifties aerospace engineers of their process protection proposal, and trying out her new version widely on real-world examples, Leveson has created a brand new method of protection that's more beneficial, less costly, and more straightforward to exploit than present recommendations. Arguing that conventional versions of causality are insufficient, Leveson offers a brand new, prolonged version of causation (Systems-Theoretic coincidence version and tactics, or STAMP), then then exhibits how the hot version can be utilized to create options for process protection engineering, together with coincidence research, risk research, process layout, safeguard in operations, and administration of safety-critical structures. She applies the recent concepts to real-world occasions together with the friendly-fire lack of a united states Blackhawk helicopter within the first Gulf struggle; the Vioxx remember; the U.S. military SUBSAFE software; and the bacterial illness of a public water offer in a Canadian city. Leveson's technique is proper even past security engineering, supplying suggestions for "reengineering" any huge sociotechnical approach to enhance protection and deal with threat.
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Additional resources for Engineering a Safer World: Systems Thinking Applied to Safety (Engineering Systems)
Leplat notes that the links are justified by knowledge or rules of different types, including physical and organizational knowledge. The same event can give rise to different types of links according to the mental representations the analyst has of Questioning the Foundations of Traditional Safety Engineering 23 the production of this event. When several types of rules are possible, the analyst will apply those that agree with his or her mental model of the situation . Consider, for example, the loss of an American Airlines B757 near Cali, Colombia, in 1995 .
Although the first event in the chain is often labeled the initiating event or root cause, the selection of an initiating event is arbitrary and previous events and conditions could always be added. Sometimes the initiating event is selected (the backward chaining stops) because it represents a type of event that is familiar and thus acceptable as an explanation for the accident or it is a deviation from a standard . 4 The backward chaining may also stop because the causal path disappears due to lack of information.
The refrigeration unit was turned off, however, to save money, and the MIC was usually stored at nearly 20°. The plant management adjusted the threshold of the alarm, accordingly, from 11° to 20° and logging of tank temperatures was halted, thus eliminating the possibility of an early warning of rising temperatures. Gauges at plants are frequently out of service . At the Bhopal facility, there were few alarms or interlock devices in critical locations that might have warned operators of abnormal conditions—a system design deficiency.