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By Nancy G. Leveson

Engineering has skilled a technological revolution, however the simple engineering thoughts utilized in security and reliability engineering, created in an easier, analog global, have replaced little or no through the years. during this groundbreaking ebook, Nancy Leveson proposes a brand new method of safety--more suited for present day advanced, sociotechnical, software-intensive world--based on sleek platforms pondering and platforms concept. Revisiting and updating rules pioneered through Nineteen Fifties aerospace engineers of their approach protection idea, and trying out her new version generally on real-world examples, Leveson has created a brand new method of security that's more suitable, more cost-effective, and more uncomplicated to exploit than present concepts. Arguing that conventional types of causality are insufficient, Leveson provides a brand new, prolonged version of causation (Systems-Theoretic twist of fate version and strategies, or STAMP), then then exhibits how the hot version can be utilized to create options for process safeguard engineering, together with twist of fate research, possibility research, process layout, protection in operations, and administration of safety-critical structures. She applies the recent suggestions to real-world occasions together with the friendly-fire lack of a U.S. Blackhawk helicopter within the first Gulf warfare; the Vioxx remember; the U.S. army SUBSAFE software; and the bacterial infection of a public water offer in a Canadian city. Leveson's strategy is appropriate even past defense engineering, delivering thoughts for "reengineering" any huge sociotechnical approach to enhance security and deal with danger.

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Air Force study of aviation accidents demonstrating that the designation of human error (pilot error in this case) is a convenient classification for mishaps whose real cause is uncertain, complex, or embarrassing to the organization. 2 Hindsight Bias The psychological phenomenon called hindsight bias plays such an important role in attribution of causes to accidents that it is worth spending time on it. The report on the Clapham Junction railway accident in Britain concluded: There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight.

3 Subjectivity in Selecting the Chaining Conditions In addition to subjectivity in selecting the events and the root cause event, the links between the events that are chosen to explain them are subjective and subject to bias. Leplat notes that the links are justified by knowledge or rules of different types, including physical and organizational knowledge. The same event can give rise to different types of links according to the mental representations the analyst has of Questioning the Foundations of Traditional Safety Engineering 23 the production of this event.

In the Bhopal accident, the vent scrubber, flare tower, water spouts, refrigeration unit, and various monitoring instruments were all out of operation simultaneously. Assigning probabilities to all these seemingly unrelated events and assuming independence would lead one to believe that this accident was merely a matter of a once-in-a-lifetime coincidence. A probabilistic risk assessment based on an event chain model most likely would have treated these conditions as independent failures and then calculated their coincidence as being so remote as to be beyond consideration.

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