The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale, you will be able to see where, in the organisational or management systems, failure occurred so that you can avoid them.
The book also describes the existence of a 'blame culture' in many organisations, which focuses on individual human error whilst ignoring the system failures that caused it. The book shows how this 'blame culture' has, in the case of a number of past accidents, dominated the accident enquiry process hampering a proper investigation of the underlying causes.
Suggestions are made about how progress can be made to develop a more open culture in organisations, both through better understanding of human error by managers and through increased public awareness of the issues. The book brings together documentary evidence from recent major incidents from all around the world and within the Rail, Water, Aviation, Shipping, Chemical and Nuclear industries.
Table of Contents
Preface. Acknowledgements. Part 1: Understanding Human Error To Err is Human. Errors in Practice. Latent Errors and Violations. Human Reliability Analysis. Human Error Modelling. Human Error in Event Sequences. Part 2: Accident Case Studies Organizational and Management Errors. Design Errors. Maintenance Errors. Active Errors in Railway Operations. Active Errors in Aviation. Violations. Incident Response Errors. Conclusions. Appendix: Train Protection Systems. Index.