Computer Control and Human Error by Trevor Kletz

By Trevor Kletz

Computer regulate and Human Error offers debts of varied incidents at computer-controlled crops. those incidents comprise gear and software program faults; treating the pc as a "black box"; misjudging the way in which operators reply to the pc; mistakes within the information access; failure to notify operators of alterations in information or courses; and unauthorized interference with peripheral apparatus. The dialogue then turns to using possibility and operability experiences (Hazops) to avoid or decrease mistakes in computer-controlled vegetation. The booklet describes the normal Hazop as utilized in the method and an summary of the several Chazop frameworks/guidelines prompt by way of engineers and researchers. It then provides new Chazop method that's in response to incident research. the ultimate bankruptcy provides purposes for disasters in automatic platforms, every one of that is illustrated with an instance. lots of the examples didn't reason a precise security challenge, just because they happened inside of structures that aren't safety-related. a few of these examples seem within the literature; others are from own adventure or from inner most communications.

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We assumed I was using an incorrect procedure and he went through the routine with me, but we used a trial file which we called ABCD! Tests should be like real life. On a control program the consequences of the wrong entry might be more serious. But no operator, asked to add 10 (one-letter-O) tonnes to a reactor would say, T can't add one-letter-0 tonnes, there's no such thing, so I'll give up'. A more friendly program would have asked me to select the file from a list rather than type its name.

There was a large spillage of cyanide material which affected the operator14. Overfilling of vessels is a frequent event and when the contents are as hazardous as cyanide they should overflow to a safe place. This incident, like many more of those I have described, would at one time have been put down to human error. But this is superficial; the accident could have been prevented (or made less likely) by better design of the display and the effects could have been mitigated by a change in plant design.

It is possible that the crash was due to a failure of the computer system but the inquiry considered this much less likely than the reason I have described. No accident has a single cause49 and in this case contributory causes were poor communication between the pilots (who had never flown together before), distraction by last minute changes by air traffic control, and the lack of a ground proximity warning system12. 6 An operator should have moved three tonnes of water into reactor A. He misread the display and moved three tonnes into reactor B which was already full.

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