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Learning from Accidents
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新春愉快！ ISBN: 075064883X Title: Learning from Accidents Author: Trevor Kletz Publisher: Butterworth-Heinemann Publication Date: 2001 Number Of Pages: 357 pages 1.59 M PDF 1 Two simple incidents 13 2 Protective system failure 22 3 Poor procedures and poor management 32 4 A gas leak and explosion – The hazards of insularity 40 5 A liquid leak and fire and the hazards of amateurism 52 6 A tank explosion – The hazards of optional extras 63 7 Another tank explosion – The hazards of modification and ignorance 73 8 Flixborough 83 9 Seveso 103 10 Bhopal 110 11 Three Mile Island 122 12 Chernobyl 135 13 Aberfan 146 14 Missing recommendations 155 15 Three weeks in a works 162 16 Pipe failures 179 17 Piper Alpha 196 18 The King’s Cross underground railway station fire 207 19 Clapham Junction – Every sort of human error 216 20 Herald of Free Enterprise 226 21 Some aviation accidents 234 22 Invisible hazards 253 23 Signals passed at danger 259 24 Longford: the hazards of following fashions 267 25 The Gresford Colliery explosion 275 26 Green intention, red result 281 27 Looking beyond violations 291 28 Keeping an open mind 297 29 Secondhand software: the Therac story 303 30 Conclusions 308 http://www.esnips.com/nsdoc/77a2 ... f7f/?action=forceDL |
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