Focus

The Blame Machine: Why Human Error Causes Accidents

January 2006

This book will help all those aiming to raise standards of health and safety in the workplace.

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.

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.