By Trevor Kletz
This name seems at how humans, in place of expertise and pcs, are arguably the main unreliable issue inside of vegetation, resulting in harmful events.
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Extra resources for An Engineer’s View of Human Error, Third Edition
4, page 56). 5, page 57). 8,page 61j. 5,page65). page 66). • 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.
A] studyfoundthatnearlyfour percentof hospital patients suffered complications from treatment which prolonged their hospital stay or resulted in disability or death, and that two-thirds of such complications were due to errors in care ... It was estimated that, nationwide, 120,000 patients die each year at least partially as a result ofsuch errors in care. 'If error were due to a subset of dangerous doctors, you might expect malpracticecases to be concentrated among a small group, but in fact they follow a uniform bell-shapeddistribution.
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. In particular, the training the operatorsreceivedhadnotequippedthemtodeal withthe eventsthat occurred. To understand these I must briefly describethe design of the pressurized water reactor of the type used at Three Mile Island, and the events of 20 March 1979.
An Engineer’s View of Human Error, Third Edition by Trevor Kletz