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Human Error: Anatomies of Accidents

Human Error: Anatomies of Accidents. Anthony J Spurgin IEEE Section Meeting 8-26--2009. Human Error: Anatomies of Accidents. Outline of Presentation Introduction Accidents cover all industries Listing of a number of accidents given Brief general discussions on some of the accidents

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Human Error: Anatomies of Accidents

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  1. Human Error: Anatomies of Accidents Anthony J Spurgin IEEE Section Meeting 8-26--2009

  2. Human Error:Anatomies of Accidents Outline of Presentation Introduction Accidents cover all industries Listing of a number of accidents given Brief general discussions on some of the accidents Role of NTSB and Human Reliability Experts View of Media Causes of Accidents, including human error In Depth Analysis of a few accidents Lessons Learned, effect of context Comments

  3. Introduction: Some Assumptions About Accidents • Everyone knows what an accident is: something that happens to others! • Usual assumptions: Random failures, and usually involving people • Humans cannot be relied upon and cause accidents • Humans have to rescue us from machine failures • Most accidents are due to single failures • We cannot do anything about accidents

  4. Analysis of Accidents • Very visible accident reports from: • Nuclear, Chemical plant, Airplanes, Railways, roads • Brief discussion about the accidents • Some accidents will be discussed some detail. • NTSB Accident reports focus on specific causes - comment • Human Reliability persons consider what are the causes of accidents and how to mitigate or minimize their effects

  5. Human Error • Are Humans prone to errors? • What leads to humans taking erroneous actions? • Careful analysis of accidents indicates that one has to consider the context under which the accident took place • The context can vary according to the accident

  6. Accident Analysis Process • Gain access to all available reports, Google, Wikipedia • Produce an independent evaluation of the events • Produce an event sequence diagram of the events • Draw conclusions relative to the various impacts on human error: design decisions, training, management involvement, etc.

  7. NASA Challenger Accident

  8. Three Mile Accident

  9. JFK AirbusAccident

  10. Boeing 747s Tenerife Accident

  11. Texas CityBP Refinery Accident

  12. Texas CityBP Plant Accident

  13. Flaujac (South West France) Railway Accident

  14. Human Error: Context Effects and other Observations • Training • Information Layout and Availability • Procedure Layout and Organization • Prior Design influences and effects • Management Influences

  15. Comments • Official Accident Reviews often result in Human Error being the cause, often the human is set-up to fail and does • PRAs rely on the combination of equipment and human error estimation to estimate the risk of operation • The PRA is a good start to the process but one can see that more needs to be done to cover things like the effects of design limits and HRA methods to be based upon context rather than the task • The predicted human error rate range is bounded and this has consequences for any designer and manager

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