Learning from accidents : investigating the genesis of human errors in multi-attribute settings to improve the organisation of design

Moura, R. and Beer, M. and Patelli, E. and Lewis, J. and Knoll, F.; Walls, Lesley and Revie, Matthew and Bedford, Tim, eds. (2016) Learning from accidents : investigating the genesis of human errors in multi-attribute settings to improve the organisation of design. In: Risk, Reliability and Safety. CRC Press/Balkema, GBR. ISBN 9781138029972

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    Abstract

    Remarkable advances in engineering and system controls in recent times and the consequent development of state-of-the-art technologies are clearly resulting in economic, environmental and safety benefits to the society. Latest disasters, however, put human error in the glare of the media spotlight. The February 2016 train collision in southern Bavaria, Germany, which took 11 lives and left more than 90 people injured, is one of several examples where human errors appear to have played a significant role in a major accident. In this emblematic case, the railway system had multiple safety barriers in place, such as an automatic braking system if a train crosses a stop signal, but the track controller had reportedly disabled it. When he realised the error and tried to warn the drivers, it was too late (BBC, 2016).