By Nancy G. Leveson
Engineering has skilled a technological revolution, however the easy engineering options utilized in protection and reliability engineering, created in a less complicated, analog international, have replaced little or no through the years. during this groundbreaking ebook, Nancy Leveson proposes a brand new method of safety--more suited for modern day complicated, sociotechnical, software-intensive world--based on smooth platforms pondering and structures concept. Revisiting and updating rules pioneered by means of Nineteen Fifties aerospace engineers of their process protection inspiration, and checking out her new version broadly on real-world examples, Leveson has created a brand new method of safeguard that's more desirable, less costly, and more uncomplicated to exploit than present thoughts. Arguing that conventional types of causality are insufficient, Leveson provides a brand new, prolonged version of causation (Systems-Theoretic twist of fate version and techniques, or STAMP), then then exhibits how the recent version can be utilized to create options for method defense engineering, together with twist of fate research, possibility research, process layout, protection in operations, and administration of safety-critical platforms. She applies the recent ideas to real-world occasions together with the friendly-fire lack of a U.S. Blackhawk helicopter within the first Gulf conflict; the Vioxx remember; the U.S. military SUBSAFE application; and the bacterial infection of a public water offer in a Canadian city. Leveson's procedure is suitable even past defense engineering, supplying innovations for "reengineering" any huge sociotechnical procedure to enhance security and deal with possibility.
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Additional info for Engineering a Safer World: Systems Thinking Applied to Safety
Example text
Alarms at the plant sounded so often (the siren went off twenty to thirty times a week for various purposes) that an actual alert could not be distinguished from routine events or practice alerts. Ironically, the warning siren was not turned on until two hours after the MIC leak was detected (and after almost all the injuries had occurred) and then was turned off after only five minutes—which was company policy [12]. Moreover, the numerous practice alerts did not seem to be effective in preparing for an emergency: When the danger during the release became known, many employees ran from the contaminated areas of the plant, totally ignoring the buses that were sitting idle ready to evacuate workers and nearby residents.
Similarly, the flare tower (which was supposed to burn off released vapor) was totally inadequate to deal with the estimated 40 tons of MIC that escaped during the accident. In addition, the MIC was vented from the vent stack 108 feet above the ground, well above the height of the water curtain intended to knock down the gas: The water curtain reached only 40 to 50 feet above the ground. The water jets could reach as high as 115 feet, but only if operated individually. Leaks were routine occurrences and the reasons for them were seldom investigated: Problems were either fixed without further examination or were ignored.
The accident model used to explain why the accident occurred should not only encourage the inclusion of all the causal factors but should provide guidance in identifying these factors. 5 Including Systems Factors in Accident Models Large-scale engineered systems are more than just a collection of technological artifacts: They are a reflection of the structure, management, procedures, and culture of the engineering organization that created them. They are usually also a reflection Questioning the Foundations of Traditional Safety Engineering 29 of the society in which they were created.
