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The Blame Machine: Why Human Error Causes Accidents and Enhancing Occupational Safety and Health

January 2006

The two books described below will help all those aiming to raise standards of health and safety in the workplace are introduced here.

The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale, you will be able to see where, in the organisational or management systems, failure occurred so that you can avoid them.

The book also describes the existence of a 'blame culture' in many organisations, which focuses on individual human error whilst ignoring the system failures that caused it. The book shows how this 'blame culture' has, in the case of a number of past accidents, dominated the accident enquiry process hampering a proper investigation of the underlying causes.

Suggestions are made about how progress can be made to develop a more open culture in organisations, both through better understanding of human error by managers and through increased public awareness of the issues. The book brings together documentary evidence from recent major incidents from all around the world and within the Rail, Water, Aviation, Shipping, Chemical and Nuclear industries.

PART 1 - UNDERSTANDING HUMAN ERROR

  • To err is human: Defining human error. Random and systemic errors.
  • Errors in practice: Genotypes and phenotypes. The skill, rule and knowledge taxonomy. The generic error modelling system taxonomy.
  • Latent errors and violations: Latent and active errors. Violations.
  • Human reliability analysis: Measuring human reliability. Human reliability methods. Task decomposition. Error identification.
  • Human error modelling: Basic probability theory. Error recovery. Error dependency.
  • Human error in event sequences: Human reliability event trees. Scenario analysis. Overview of human error modelling.

PART 2 - ACCIDENT CASE STUDIES

  • Organizational and management errors: The Flixborough chemical plant disaster. The capsize of the Herald of Free Enterprise. Privatisation of the railways.
  • Design errors: The fire and explosion at BP Grangemouth. The sinking of the ferry 'Estonia'. The Abbeystead explosion.
  • Maintenance errors: Engine failure on the Royal Flight. The railway accident at Hatfield. The railway accident at Potters Bar.
  • Active errors in railway operations: Signals passed at danger. The train accident at Purley. The driver's automatic warning system. The Southall and Ladbroke Grove rail accidents. Human error analysis of signal passed at danger. Driver protection against SPADs.
  • Active errors in aviation: The loss of flight KAL007. The Kegworth accident.
  • Violations: The Chernobyl accident. The Airbus A320 crash at Mulhouse.
  • Incident response errors: Fire on Swissair flight SR111. The Channel Tunnel fire.
  • Conclusions: Human error and blame. Understanding human error. Human error in industry.

Appendix: Train protection systems.

Readership: Students on occupational psychology, occupational health and safety, insurance and risk management courses, especially those on BSc and MSc Occupational Health and Safety courses. Safety practitioners in manufacturing and transportation industries; managers; accident investigators and safety regulators; liability surveyors.

The Blame Machine: why human error causes accidents, by R.B. Whittingham | Elsevier Butterworth-Heinemann | ISBN: 0-7506-5510-0 | Book/Paperback | 288 pages | www.elsevierdirect.com

Barry Whittingham has worked as a senior engineer, design engineer and consultant for the chemical, nuclear, offshore oil and gas, railway and aviation sectors. He developed a career as a safety consultant specializing in the human factors aspects of accident causation. He is a member of the Human Factors in Reliability Group, and a Fellow of the Safety and Reliability Society.

Enhancing Occupational Safety and Health

In this comprehensive guide to occupational safety and health (OSH or OHS), the authors have taken an international and holistic perspective, foregoing regional prescriptive models for a self-regulatory, risk management-based approach to health and safety at work.

Both technical and human factors are considered in all areas of health and safety management - from hazardous substances and radiation, noise and vibration, to ergonomics, stress, substance abuse, and violence. The book outlines strategies for managing workers' compensation claims and rehabilitation, and for assessing training needs and evaluating courses. It also explains how to implement an overall occupational health and safety management system in a company, integrating this into existing quality management programs.

Each chapter includes a workplace application, further reading recommendations, and end-of-chapter questions, making this an ideal text for students on all health and safety related vocational and university courses. The book is also suitable for students on management courses, in which health and safety is being increasingly included in the syllabus. Managers, both general and health & safety professionals, will find this an invaluable international reference to the current concepts.

Contents

Current concepts: Common Terms. Key factors in the development of workplace accident prevention. The American Scene and the Birth of Accident Prevention. Accident Costs from workplace injuries and damage. Issues in the work environment affecting employee well-being. Further Reading. Appendix - Practical Risk analysis for safety management.

Common and statute law: Origins and types of law which influence OHS. Duty of Care. OHS legislation. Legislation in accident prevention in the US and EU. Further reading.

Hazard and risk management: Risk concepts. Role of hazards in injury causation. Planned hazard identification, formal and informal systems. Risk assessment. Principles behind risk assessment and importance and limitations of scientific assessment. Understanding risk. Risk control. Further reading.

Workplace inspections: Standard setting and formal and informal inspection. Structured and documented inspections. Format for inspections and reporting. Conducting a safety audit and preparing a report.

Accident prevention: Accident causation factors. Identifying the factors. Elements of the work system influencing OHS. Basic human behavioural aspects of accident and injury occurrence. Accident Investigation. Principal elements in developing a workplace heath and safety plan. Accident, injury, compensation and safety data. Collecting, sorting accessing and validating data. Data handling and analysis. Data reporting to management. Violence in the workplace. Appendix Accident models. References to accident models. Further reading.

Risk engineering: Electrical safety. Fixed machinery hazards. Safe use of pressure vessels and lifting equipment. Fire hazard identification and extinguisher use. Fire safety managers. Building regulations and fire safety compliance. Determining building classifications, fire loads and fire resistance. Preparing a technical brief of fire safety requirements for a building. The human element in fire causation and behaviour during fire emergencies. Locking systems - Security versus safe egress. Fire prevention and emergency training program. Further reading.

Hazardous substance management: Chemical elements, compounds, classes and physical state. Common chemical hazard classes and descriptors. Chemical reactions and structures. Classifying chemicals. Main factors in transport of hazardous chemicals. Dangerous goods vehicle and driver checks. Storage of hazardous substances. Information sources on chemical hazards. Procedures for receipt and dispatch of hazardous substances. Specialist facilities for the management of hazardous substances. Controls to minimize employee exposure. Role of emergency personnel. Further reading.

Health at work: Development history of occupational health. Current developments in occupational health. Workplace diseases, causes and toxins. Links between workplace stressors, processes and diseases. Worker health monitoring. Stressors inside and outside the workplace. Alcohol and drugs in the workplace. Further reading.

Work environment: Major characteristics of noise. Control of excessive noise. Ergonomic Principles and control of noise, vibration and lighting hazards. Conducting a noise survey. Measuring light levels. Air contaminant measurement. Thermal comfort and heat stress. Vibration. Non-ionising radiation. Ionising radiation. Further reading.

Ergonomics: Origins and History. The person-machine model. Anthropometry. Relative merits of methods of collecting and applying anthropometric data. Common forms of occupational overuse syndrome and preventative ergonomic strategies. Methods for identification, assessment and control of manual handling hazards. Assessment of manual handling tasks. Prevention of manual handling injuries. Assessing the energy cost of work. Ergonomic principles associated with integration of controls and displays. Job design structure. Ergonomic principles and design and redesign of workstations. Ergonomics and workstation design. Human error. Further reading.

Workers compensation and rehabilitation: Development of employer's liability. Employer's liability for compensation under workers compensation legislation. Process for resolving disputes in workers compensation. Principles of rehabilitation applying to injured workers. Role of rehabilitation in the workers compensation system. Factors in an effective injury management system. Assistance in rehabilitation of employees. Negotiation of premium level with the insurer. Effective claims management. Further reading.

Health and safety training: Safety and health training programs. Education and training needs. Assessment methods. Options for training delivery. Choosing and performing appropriate follow-up activities to evaluate a training session (or program). The importance of procedures. Further reading.

Safety management: Safety and health in risk management. Formal and informal safety meetings. Nature, occurrence and industrial relations implications of OHS issues. Prioritising and developing strategies to resolve OHS issues. Budget planning, control of safety expenditure and supervision. Best practice in work safety. Contractor safety. Behaviour based safety. Communication and meeting skills. Further reading.

Health and safety management systems: Options for management of OHS in an organisation. Strategies to integrate OHS into organisational quality management systems. Proposing and defending a strategy for management of change. Reviewing an occupational health and safety management system. Cost-benefit analyses for new acquisitions, refurbishments or maintenance. Further reading.

A Learning System to support studies of this book is available at www.enhancingsafety.com

Readership: Academic students, especially undergraduates. Safety professionals. Human Resources managers with responsibility for H&S issues. Industrial hygienists; environmental managers with responsibility for H&S issues; Health & Safety practitioners; risk managers; occupational hygienists; environmental health officers.

Enhancing Occupational Safety and Health, by Geoff Taylor, Kellie Easter and Roy Hegney | Elsevier Butterworth-Heinemann | ISBN: 0-7506-6197-6 | Book/Paperback | 599 pages | www.elsevierdirect.com

Geoffrey A. Taylor M. Sc. (Occ. Hyg.), Grad. Dip. Bus. Admin, Chartered Fellow, Safety Institute of Australia, Dip. Occ. Hyg. (UK), C.I.H. (US), MAIOH.
Director, Work Safety and Health Associates, Riverton, Australia.

Kellie Easter Grad. Dip. OHS (Curtin), RGN, MSIA.
Lecturer, Australian Centre for Work Safety, Swan College of Technical and Further Education, Perth, Australia.

Roy Hegney Grad. Dip. OHM (Ballarat), Grad. Dip. Ed. Training and Development (ECU)
Lecturer, Australian Centre for Work Safety, Swan College of Technical and Further Education, Perth, Australia.

 

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