Know the Risk: Learning from errors and accidents: safety and risk in today's technology

259 Pages·2002·19.98 MB·English

by  Romney Duffey Ph.D. B.Sc.

KNOW THE RISK
KNOW THE RISK
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KNOW THE RISK
Learning from Errors and Accidents:
Safety and Risk in Today's Technology
Romney Beecher Duffey
John Walton Saull
I'~UTTE RWO RTH
I~I E 1 N E M A N N
An imprint of Elsevier Science
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Copyright (cid:14)9 2003, Romney Beecher Duffey and John Walton Saull.
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Library of Congress Cataloging-in-Publication Data
Duffey, R. B. (Romney B.)
Know the risk : learning from errors and accidents : safety and risk in today's
technology / Romney Beecher Duffey, John Walton Saull.
p. cm.
Includes bibliographical references and index.
ISBN 0-7506-7596-9 (alk. paper)
1. Industrial safety. I. Saull, John Walton. II. Title.
T55 .D815 2003
620.8'6--dc21 2002026289
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Cover: Every day there are new accidents: montage illustrating the opportunities for
and the consequences of human errors.
Photograph/Image credits--clockwise from top--courtesy of:
Grounded Ship: U.K. Department of the Marine Accident Investigation Board (MAIB)
http ://www.maib.detr.gov.uk/
Crashed Vehicle: U.S. Department of Transportation, National Highway Traffic Safety
Administration (NHTSA) http://www.nhtsa.dot.gov
Burning Loader: U.S. Department of Labor Mine Safety and Health Administration
(MSHA) http://www.msha.gov
Airplane in Sea: Harro Ranter, Aviation Safety Network, http:Haviation-safety.net/
pictures/index.html
Train Collision: Department of Transport and Regional Services, Australian Transport
Safety Bureau (ATSB) http://www.basi.gov.au
Pressure Vessel Explosion: U.S. Department of Labor Mine Safety and Health Admin-
istration (MSHA) http://www.msha.gov
Plant Operator: Romney B. Duffey, Photo Archive
Minimum: the smallest, least quantity, amount or point possible
Error: mistaken belief fault, mistake, something done amiss
Risk: possibility or likelihood of danger, injury, loss, etc.
Theory: a general proposition, to explain a group of phenomena
m Universal English Dictionary
CONTENTS
Preface /x
Dedication and Acknowledgments xi
About the Authors xiii
Introduction: Are You Safe?
Chapter 1 Measuring Safety 15
1.1 Safety in Numbers: The Statistics and Measures
of Death and Risk 15
1.2 Experience Counts: Accumulating Experience 16
1.3 Error and Accident Rates: The Instantaneous,
Accumulated, and Constant Rates 20
Chapter 2 Traveling in Safety 31
2.1 The Crashes of Aircraft: The Concorde 31
2.2 The Sinking of Ships" Titanic and Today 47
2.3 The Safety of Roads" Accidents with Cars and Trucks 60
2.4 The Railways: From the Rocket to Red Lights at Danger 77
Chapter 3 Working in Safety 89
3.1 Industrial Errors and Chernobyl 89
3.2 Almost Completely Safe Systems 98
3.3 Using a Bucket: Errors in Mixing at the JCO Plant 99
3.4 Chemical and Nuclear Plants 101
3.5 Human Error at Work 111
VI.o I
viii Contents
Chapter 4 Living in Safety 123
4.1 Risky Choices 123
4.2 Medical Safety: Misadministration, Malpractice,
Drugs, and Operations 124
4.3 Terror in Technology 139
4.4 Drinking Water: Walkerton and Sydney's Risk 143
4.5 Accidental Deaths and Incidental Insurance 154
Chapter 5 Error Management: Strategies for Reducing Risk 159
5.1 Quality Management and the Dream of Zero Defects 159
5.2 A Learning Environment: Safety and Quality Management 162
5.3 Measuring and Managing Our Risk: In a Nutshell 162
5.4 Speculations on the Active Minimum Error Rate 166
5.5 Universal Learning Curves: Validating the Theory 171
5.6 Errors and Technology: Are You Safe? 174
Appendix A: Universal Learning Curves and the Exponential
Model for Errors, Incidents, and Accidents 179
Appendix B" Extracts from Event Investigations and Inquiries 193
Appendix C: References, Bibliography, and Sources 201
Nomenclature 211
Index 213
PREFACE
"Whatever happens, I'll leave it all to chance."
n Queen
ERRORS IN TECHNOLOGY: HOW SAFE ARE YOU?
We live in a technological world, exposed to risks and errors and the fear of death. The
aim of our book is to show how we can learn from the many errors and tragic accidents
which have plagued our developing technological world. These startling reminders of
our mortality threaten us all, putting us at risk of death or injury. To understand the risks
we face, how to minimize them and predict the future, we need to challenge you to
think about "How safe are you?"
The book explores many headline accidents which highlight human weaknesses in har-
nessing and exploiting the technology we have developed--from the Titanic to Cher-
nobyl, Bhopal to Concorde, the Mary Rose to the Paddington rail crash--and we
examine errors over which we have little or no control.
By analyzing the vast sets of data society has collected, we can show how the famous
accidents and our everyday risks are related. We look at:
(cid:12)9 Traveling in safety
(cid:12)9 Working in safety
(cid:12)9 Living in safety
The reader is led through the extensive data we have collected, systematically exam-
ining each of these areas (see contents) using data and examples of actual events and
illustrative narrative. We discover how the common threads of the sequences and the
differing confluence of human actions link these errors with machines.
ix