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Accidents = Mishap (System failures (Imperfections (Made by imperfect ppl)…
Accidents = Mishap
System failures
Imperfections
Made by imperfect ppl
Read the books and the journal articles
Design Phase
Construction Phase
Commissioning & Start-up phase
Operations Phase
MoC failures
De-commissioning phase
Hierarchy of control failures
ALARP
Poor investigations
Financial constraints
Poor training/competency assurance
Schedule constraints
Market constraints
Human errors
Natural imperfections
(Uncontrollable)
Need to sleep/eat/etc..
Many ppl—> shift rosters
Handovers quality
Automation (Robots)
ALARP
can't focus on 2 things at once equally
Unpredictable mood changes
Automation (Robots)
Unable to maintain full awareness continually
Ignorance
(Controllable)
Simple ignorance
(Unintentional)
Aware of ignorance
honest mistakes and violations (deliberate)
Can be fixed proactively but not entirely without removing the human
Compound ignorance
Unaware of ignorance
Harder than simple to detect and fix proactively
Violations (Intentional)
Can be fixed
Known unknowns
Epistemology of human error
Failure of org
Epistemology of accident
External Factors
Weather
Ontology
Definition of reality