By Trevor Kletz
This name appears to be like at how humans, in preference to expertise and pcs, are arguably the main unreliable issue inside vegetation, resulting in harmful events.
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Additional resources for An Engineer’s View of Human Error, Third Edition
A contributory cause was the failure of the signalman who had just gone off duty to inform the signalmanin the next signalbox that the line was blockedand to put a remindercollaron the signal lever. One signalman had a lapse of memory — and obviously it was not deliberate. The other signahnan was taking short cuts — omitting to carry out jobs which he may haveregardedas unnecessary. 2 What shouldwe do? As in the other incidentsdiscussedin this chapter, there are three ways of preventing similarincidents happemng again: (1) Changethe hardware.
19. , 1987, DangerSignals(Ian Allen, London,UK). 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.
After the accident a 'repeater' was installed to improve its visibility. The managerswho did not provide the equipment that could have prevented the accident were not, of course, unconcerned about safety. At worst they did not understand the nature of humanerror; at best they may have decided that more lives would be savediftherailway'sresources were spentin other ways. Followinga similar accident in 1996, another driver was prosecuted for manslaughter but acquitted40. Davis11 has analyseda numberofcasesin detail and has shownthat while a few of the drivers were clearly unsuited to the job, the majority were perfectly normal men with many years' experience who had a moment's aberration.
An Engineer’s View of Human Error, Third Edition by Trevor Kletz