By Trevor Kletz
This identify seems at how humans, instead of expertise and desktops, are arguably the main unreliable issue inside of crops, resulting in harmful occasions.
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Extra resources for An Engineer’s View of Human Error, Third Edition
090, page29. 22. As Reference 19, page 126. 23. Hidden, A. 12 (HMSO,London, UK) 24. Evening Gazette (Middlesbrough), 24 and 25 August 1987. 25. Miller, J. USA). 26. Operating Experience Weekly Swnmaiy, 1998, No. 98—52, page 3 (Office of NuclearandFacilitySafety,US Department ofEnergy, Washington, DC, USA). 27. Operating Experience Weekly Summary, 1999, No. 99—17, page 1 (Office of Nuclearand FacilitySafety,US Department ofEnergy, Washington. DC. USA). 28. Sykes,W S. 1960, Essayson the First HundredYearsofAnaesthesia, Chapter1 (Churchill Livingstone, Edinburgh, UK).
Error experts, therefore, believe that it's the process, not the individuals in it, whichrequirescloserexanilnation and correction. In a sense they want to industrialize medicine. Checkson the air-conditioning system and a search for infectionproducedno clues. Finally, the cause was discovered: every Friday morning a cleaner unplugged the life support systemand pluggedin her floor polisher. When she had finished she replaced the plug on the life-supportsystem but by now the patient was dead. She did not hear any screams above the noise madeby the floor polisher33.
Water ... The hypnotized subject was thenordered to throw the dish ofnitric acid (in actual fact, of course, innocuous water) over the assistant who was present in the same room. Underthese conditions it was possible to induce, under hypnosis, various subjects to throw what they considered to be an extremely dangerous acid into the face of a human being ... '16 'A deplorable accident has taken place at the Grenoble Lycée. The professorofchemistry was lecturingon salts of mercury, and had by his side a glass full of a mercurialsolution.
An Engineer’s View of Human Error, Third Edition by Trevor Kletz