Mr. Trevor Kletz is, without a doubt, my favorite author. In 2001 he published his book on Human Factors in process safety – “An engineer’s view of human error” (Third edition). It is a MUST-READ for those who practice process safety, significantly if you facilitate process hazard(s) analysis (PHA), including the Human Factors analysis. His book is quite telling, as evidenced by the title of Chapter 1 – Accept men as we find them. On the book’s cover, Mr. Kletz states the theme: Try to change situations, not people. Part 2 of the book is titled Accidents caused by simple slip, which is a play on Dr. James Reason’s Human Failure Model of Errors, Mistakes, and Violations.
| If all accidents are due to human errors, how does this book differ from any other book on accidents? It describes accidents which at first sight seem to be due wholly or mainly to human error, which at one time would have been followed by exhortations to take more care or follow the rules, and emphasizes what can be done by changing designs or methods of working. The latter phrase includes training, instructions, audits, and enforcement as well as the way at ask is performed. |
Here is the full table of contents:
1 Introduction
1.1 Accept men as we find them
1.2 Meccano or dofs? 3
1.3 Types of human error 4
1.4 Two simple examples 6
1.5 Accident investigation 8
1.6 A story 9
1.7 Research on human error 10
2 Accidents caused by simple slips
2.1 Introduction 11
2.2 Forgetting to open or close a valve 13
2.3 Operating the wrong valve 21
2.4 Pressing the wrong button 25
2.5 Failures to notice 29
2.6 Wrong connections 31
2.7 Errors in calculations 32
2.8 Other medical errors 34
2.9 Railways 35
2.10 Other industries 41
2.11 Everyday life (and typing) 43
2.12 Fatigue 45
3 Accidents that could be prevented by better training or instructions
3.1 Introduction 48
3.2 Three Mile Island 50
3.3 Other accidents that could be prevented by relatively sophisticated training 53
3.4 Accidents that could be prevented by elementary training 62
3.5 Contradictory instructions 65
3.6 Knowledge of what we don’t know 66
3 7 Some simple ways of improving instructions 67
3.8 Training or instructions? 72
3.9 Cases when training is not the best answer 74
4 Accidents due to a lack of physical or mental ability
4.1 People asked to do the physically difficult or impossible 78
4.2 People asked to do the mentally difficult or impossible 80
4.3 Individual traits and accident proneness 85
4.4 Mind-sets 88
5 Accidents due to failures to follow instructions
5.1 Accidents due to non-compliance by managers 99
5.2 Accidents due to non-compliance by operators 103
5.3 Actions to improve compliance 107
5.4 Alienation 109
5.5 Postscript 110
6 Accidents that could by prevented by better management
6.1 An accident caused by insularity 114
6.2 An accident due to amateurism 115
6.3 The fire at King’s Cross railway station 116
6.4 The Herald of Free Enterprise 117
6.5 The Clapham Junction railway accident 118
6.6 Piper Alpha 120
6.7 What more can senior managers do? 120
6.8 The measurement of safety 125
6.9 Conclusions 127
7 The probability of human error
7.1 Why do we need to know human error rates7 130
7.2 Human error rates — a simple example 132
7.3 A more complex example 132
7.4 Other estimates of human error rates 136
7.5 Two more simple examples 141
7.6 Button pressing 144
7.7 Non-process operations 146
7,8 Train driver errors 147
7.9 Some pitfalls in using data on human reliability 147
7.10 Data on equipment may be data on people 149
7.11 Who makes the errors7 151
7.12 Conclusions 151
8 Some accidents that could be prevented by better design
8.1 Isolation of protective equipment 155
8.2 Better information display 156
8.3 Pipe failures 156
8.4 Vessel failures 159
8.5 The Sellafield leak 159
8.6 Other design errors 161
8.7 Conceptual shortcomings 162
8.8 Problems of design contractors 165
8.9 Domestic accidents 166
9 Some accidents that could be prevented by better construction
9.1 Pipe failures 168
9.2 Miscellaneous incidents 170
9.3 Prevention of construction errors 173
10 Some accidents that could be prevented by better maintenance
10.1 Incidents which occurred because people did not understand how equipment worked 175
10.2 Incidents which occurred because of poor maintenance practice 178
10.3 Incidents due to gross ignorance or incompetence 180
10.4 Incidents which occurred because people took short cuts 181
10.5 Incidents which could be prevented by more frequent or better maintenance 183
10.6 Can we avoid the need for so much maintenance? 185
11 Some accidents that could be prevented by better methods of operation
11.1 Permits-to-work 187
11.2 Tanker incidents 189
11.3 Some incidents that could be prevented by better instructions 192
11.4 Some incidents involving hoses 193
11.5 Communication failures 194
11.6 Examples from the railways 199
11.7 Simple causes in high tech industries 201
12 Errors in computer-controlled plants
12.1 Hardware failures 204
12.2 Software errors 205
12.3 Specification errors 207
12.4 Misjudging responses to a computer 210
12.5 Entering the wrong data 213
12.6 Failures to tell operators of changes in data or programs 214
12.7 Unauthorized interference with hardware or software 214
12.8 The hazards of old software 217
12.9 Other applications of computers 217
12.10 Conclusions 218
13 Personal and managerial responsibility
13.1 Personal responsibility 221
13.2 Legalviews 223
13.3 Blame in accident investigations 227
13.4 Managerial wickedness 228
13.5 Managerial competence 229
136 Possible and necessary 231
14 The adventures of Joe Soap and John Doe
15 Some final thoughts