By Trevor Kletz
, Pages iii-iv
, Page vii
, Pages 1-2
1 - a few incidents that experience happened, typically in computer-controlled procedure plants
, Pages 3-44
2 - chance and operability (hazop) stories utilized to computer-controlled method plants
, Pages 45-80
3 - the explanations why computer-controlled structures fail
, Pages 81-113
, Pages 114-116
, Pages 117-120
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Additional info for Computer Control and Human Error
The inertial navigation system guided the plane, which was flying low so that the passengers could see the scenery, along a valley that ended in a cliff. It looked very similar to the open-ended valley that the crew expected to follow; they did not realize they were on the wrong course and they flew into the cliffs. All 257 people on board were killed50'51 (see Chapter 3, Section 10, page 97). 8. 1 Unauthorized interference with computer electronics is difficult, but interference with peripheral equipment may be more serious than on a traditional plant as the computer does not know that interference has occurred.
1990, A Manager's Guide to Reducing Human Errors (Chemical Manufacturers Association, Washington, DC, USA), 18. , January 1990, Flight International, 42. 1 September 1986, Time, p. 24. , 1994, Learning from Accidents, 2nd edition (Butterworth-Heinemann, Oxford, UK). , 1984, Verdict on Erebus (Collins, Auckland, New Zealand). , November 1984, Readers Digest, 164-200. Kletz, T. , 1994, What Went Wrong—Case Histories of Process Plant Disasters (Gulf Publishing Company, Houston, TX, USA), Chapter 1.
An earlier study (Hazard Study 0) is now being introduced. It is carried out at the start of a project, before the engineering design department is involved, and asks if the right product is being made by the most suitable route and in the most suitable location. Two related hazard identification techniques — FMEA (Failure Modes and Effects Analysis)13 and FMECA (Failure Modes Effects and Criticality Analysis) — will also be referred to later in this chapter. In contrast to Hazop, FMEA and FMECA represent a 'bottom up' approach to hazard identification.