xxii PREFACE

In Part A, some of the chapters covered different types of equipment,

whereas others covered procedures such as maintenance or modifications.
In Part B, most of the chapters cover procedures, but a number of reports
on explosions and leaks are collected under these headings. This part also
emphasizes the multiple causes of accidents. As a result, the accidents
described in the chapter on the management of change, for example, also
have other causes, whereas some incidents in other chapters also involve
the management of change. Similarly, several scattered reports show that
some accidents cannot be prevented by more detailed instructions but
only by giving people a better understanding of the process. This makes
the allocation of incidents to chapters rather arbitrary, so I have included
many cross-references and a comprehensive index.
Missing from this book is a chapter on human error. This is because
all accidents are due to human error. Someone, usually a manager or
supervisor, has to decide what to do; someone, often a designer, has to
decide how to do it; someone, usually an operator, has to do it. All may
make errors, of different sorts, for different reasons. Human errors are too
diverse to be treated as a single group, and I find it useful to classify them
as follows:
Mistakes. They occur because someone does not know what to do. To
prevent them, we need better training or instructions or changes to the
plant design or method of working so that the task is easier.
Violations or noncompliance. They occur because someone decides not to
follow instructions or recognized good practice. They are the only
sort of error for which blame might be justified. It is not justified if the
supervisors had turned a blind eye or if the violations had been going
on for a long period and, unknown to the supervisors, had become
custom and practice. Many violations are made with good intentions,
and if the instructions are wrong a violation may prevent an accident.
To prevent violations, we should explain the reason for instructions,
carry out occasional checks to make sure they are being followed, and
never turn a blind eye when they are not. We should also, when pos-
sible, simplify procedures that are difficult to follow.
Mismatches. The job is beyond the mental or physical ability of the person
asked to do it, perhaps beyond anyone’s ability. We should change the
design or method of working.
Slips and lapses of attention. These are inevitable from time to time, so we
should change designs or methods of working so as to remove oppor-
tunities for human error.
This classification is discussed in more detail in Chapter 38. An under-
lying principle behind this book is that whenever possible we should
remove situations that are error-prone rather than expect people to never
make errors. There is more about human error in my book An Engineer’s