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

By Trevor Kletz

This identify appears to be like at how humans, in preference to expertise and pcs, are arguably the main unreliable issue inside of vegetation, resulting in risky events.

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Additional resources for An Engineer’s View of Human Error, Third Edition

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Following further accidents, in 1989 British Railways agreed to implementa system over a period of ten years23. However, the cost turned out to be excessive and the Governmentrefused to authorize it. Ten years later, no changes had been made and Railtracl, the now privatized successor to British Railways, agreed to adopt a simpler but less effective system than that originally proposed. In the Train Protection and Warning System (TPWS), as it is called, the speedof a train is measured. Ifit is approaching a danger signal, a buffer stop or a speed restriction too rapidly, the brakes are cancelled applied automatically.

Following further accidents, in 1989 British Railways agreed to implementa system over a period of ten years23. However, the cost turned out to be excessive and the Governmentrefused to authorize it. Ten years later, no changes had been made and Railtracl, the now privatized successor to British Railways, agreed to adopt a simpler but less effective system than that originally proposed. In the Train Protection and Warning System (TPWS), as it is called, the speedof a train is measured. Ifit is approaching a danger signal, a buffer stop or a speed restriction too rapidly, the brakes are cancelled applied automatically.

The author goes on to suggest ways of reducing medical errors. 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.

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