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Additional resources for An Engineer’s View of Human Error, Third Edition
A minuteor so later the north-bound express train ran into the wreckage. The woodencoachesof the troop train caughtfire and many ofthose who survived the first impact were burned to death. The accident occurred becausethe signalmanforgotthat there was a train on theup line, thoughhe could see it from his windowand hadjust got offit, and accepted another train. A contributory cause was the failure of the signalman who had just gone off duty to inform the signalmanin the next signalbox that the line was blockedand to put a remindercollaron the signal lever.
20 March 1980, page216. 18. Nock. S. London, UK). 19. , 1987, DangerSignals(Ian Allen, London,UK). 20. , 1968, Traiiz Wrecks (Bonanza Books, New York, USA). 21 LossPreventionBulletin, 1989. No. 090, page29. 22. As Reference 19, page 126. 23. Hidden, A. 12 (HMSO,London, UK) 24. Evening Gazette (Middlesbrough), 24 and 25 August 1987. 25. Miller, J. USA). 26. Operating Experience Weekly Swnmaiy, 1998, No. 98—52, page 3 (Office of NuclearandFacilitySafety,US Department ofEnergy, Washington, DC, USA).
The valveson reactorsunder maintenance shouldhave been defused and locked off and the inlet and exit lines should have been slip-plated. The operator was not to blamefor the accident. He made the sort of error that everyone makes from time to time. The accident could have been prevented by a better method ofworking, bybetter management. 12(a) (page 30). 12(b) (page 30). An operator was asked to close the fuel valve on No. 5 furnace. He pressedthe wrong button and isolatedthe fuel to A furnace. He realizedthat he had to isolate the fuel to thefurnaceon theextreme left so he went to the buttonon the extremeleft.
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