By Trevor Kletz
This identify appears to be like at how humans, in preference to expertise and desktops, are arguably the main unreliable issue inside vegetation, resulting in harmful occasions.
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Extra resources for An Engineer’s View of Human Error, Third Edition
Checkthatinstructions areeasytoread,readilyavailableandwrittentohelp thereader ratherthan protect thewriter. 7, page 67). • Train people to diagnose faults and act accordingly. 8, page 72). 3, pages 53 and 54). Discussions are better than lectures or writing as people have an opportu- nity forfeedbackand theyremembermore. Sometimes accidents have occurred because of a lack of sophisticated training, as at Three Mile Island; sometimes because of a lack of basic training. 32 Three Mile Island The accidentat Three Mile Island nuclearpower station in 1979 had many causesand many lessons can be drawn from it"2 but some of the mostimportant ones are concernedwith the human factors.
Despite these two incidents, calculation errors by designers are comparativelyrare andI do not suggest any changes to normal design procedures. Whatdoes not look right. may not be right. As theresult of a calculation error,anewbornbaby was killed by an overdose ofa drug. A doctor, workingunder stress, gavethe baby 10 micrograms of a drug, per kg of body weight, instead of 1 microgram/kg. The baby's weight was reported in pounds and the error occurred in converting them to kg. An inquiry found the doctors involved ilot guilty of serious professional misconduct.
The operator pointed out that the key was small and easily overlooked and that the indicator lights were not easily visible when the sun was shining. As an immediate measure a large metal tag was fitted to the key. ) Later the drain and feed valves were interlocked so that only one ofthemcould be open at a time. 4. When the reaction was complete the pressure fell and the product was discharged into the product tank. 3 bar. A drain valvewas providedfor use after the reactorwas washed out with water between batches.
An Engineer’s View of Human Error, Third Edition by Trevor Kletz