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Index
Cover
Half Title
Title Page
Copyright Page
Contents
Preface
Acknowledgments
Authors
Chapter 1 Introduction
1.1 Purpose of the Book
1.2 Potential Use of the Book
1.3 Philosophy of the Authors
Chapter 2 Background
2.1 Introduction
2.2 Applications of Technology
2.2.1 Submarines
2.2.2 Aircraft Development
2.2.3 Computers
2.2.4 Instruments
2.3 Comments
Chapter 3 Cybernetic Organizational Model
3.1 Overview
3.2 Controller Design and Operation
3.3 Controller Response
3.4 VSM System
3.5 Use of Feedback in VSM
3.6 Complexity of Operations
3.7 Enhanced VSM Representation
3.8 VSM Application to Aircraft Traffic Control Study
3.9 ATC in Saudi Air Space
3.10 Analysis of the ATM Operation
3.11 Human Reliability Assessment
3.12 Linking VSM and CAHR
3.13 Comments
3.14 Summary
Chapter 4 Ashby’s Law of Requisite Variety and Its Application
4.1 Introduction
4.2 General Approach to Control of Systems
4.3 Impact of Ashby’s Law
4.4 Examples: Application of Ashby’s Law
4.4.1 Fermi’s Chicago Pile (CP1) Nuclear Experiment and Xenon
4.4.2 Effect of Management Decisions on the Fukushima Accident Progression
4.4.3 Failure of San Onofre NPP Steam Generators
4.5 Methods to Enhance the Probability of Good Decision-Making
4.6 Conclusions
Chapter 5 Probability Risk Assessment
5.1 Introduction to PRA
5.2 PRA Structure
5.3 Applications of PRA
5.4 Summary
Chapter 6 Rasmussen’s Human Behavior Groups
6.1 Introduction to Skill-, Rule-, and Knowledge-Based Behavior
6.2 Application of Skill, Rule, Knowledge Behavior Rules
6.3 Comments
Chapter 7 Case Studies of Accidents for Different Industries
7.1 Scope: Analysis of Accidents
7.2 Accidents: Analysis Approach
7.3 List of Accidents
7.4 Nuclear Industry Accidents
7.4.1 Three Mile Island Unit #2
7.4.1.1 Accident Analysis
7.4.1.2 Organizational Analysis
7.4.1.3 Review of a VSM Model following TMI Organizational Analysis
7.4.2 Chernobyl
7.4.2.1 Description of Plant
7.4.2.2 Accident Description
7.4.2.3 Accident and Organizational Analysis
7.4.2.4 Comments on Chernobyl Organization
7.4.3 Fukushima Daiichi Accident
7.4.3.1 TEPCO and Fukushima Plant Organizations
7.4.3.2 Comments on the Preaccident Status
7.4.3.3 Accident Description
7.4.3.4 TEPCO Daiichi Organization—Prior to Accident
7.4.3.5 Reorganized Daiichi during Response to Emergency
7.5 Chemical Industries
7.5.1 Union Carbide Sevin (Pesticide) Plant, Bhopal, India, 1984
7.5.1.1 Introduction
7.5.1.2 Accident Analysis
7.5.1.3 Organizational Analysis
7.6 Oil and Gas Industries
7.6.1 Deepwater Horizon/Macondo Blowout Gulf of Mexico Oil Accident
7.6.1.1 Introduction
7.6.1.2 Accident Description
7.6.1.3 Accident Analysis
7.6.1.4 Organizational Analysis
7.6.1.5 Conclusions
7.6.1.6 Organization (VSM) Comments
7.6.1.7 Postscript on the Macondo Well Accident
7.7 Railways
7.7.1 Introduction
7.7.1.1 Kings Cross Underground Fire, November 18, 1987
7.7.1.2 Organization Analysis
7.7.1.3 Comments on Railway Accidents
7.8 NASA and Air Transport
7.8.1 NASA Challenger Accident, January 28, 1986
7.8.1.1 Background
7.8.1.2 Description of the Shuttle
7.8.1.3 Analysis
7.8.1.4 Description of Accident
7.8.1.5 Accident Analysis
7.8.1.6 Comments
7.8.2 Tenerife, Canary Islands Runway Accident, March 1977
7.8.2.1 Background
7.8.2.2 Accident Location
7.8.2.3 Accident: Sequence of Events
7.8.2.4 Analysis
7.8.2.5 Comments
7.9 Ancillary Safety-Related Incidents
7.9.1 NPP Containment Sump Blockage
7.9.2 Hungarian VVER Fuel Cleaning Accident
7.9.3 San Onofre NPP: Replacement Steam Generators
7.9.4 Northeast Utilities: Impact of Management Change
Chapter 8 Lessons Learned from a Series of Accidents
8.1 Introduction
8.2 Listing of the Lessons Learned for Each Accident
8.2.1 Three Mile Island Unit #2 Accident
8.2.2 Chernobyl Accident
8.2.3 Fukushima Accident
8.2.4 Bhopal Accident
8.2.5 BP Oil Refinery Accident
8.2.6 Deepwater Horizon/Macondo Oil Release Accident
8.2.7 Railways Accidents, Including Subsurface Railways
8.2.8 NASA Challenger Accident
8.2.9 Tenerife Accident
8.2.10 NPP Containment Sump Blockage
8.2.11 Fuel Cleaning Accident
8.2.12 Replacement of Steam Generators
8.2.13 Impact of Management, NU Operations
8.3 Summary
Chapter 9 Role of Regulation in Industrial Operations
9.1 Introduction
9.2 Regulation Process
9.3 Lessons from Review of NRC Reports
9.3.1 Comment on Report
9.4 Comments
Chapter 10 Integration of Tools Related to Decision-Making
10.1 Introduction
10.2 Integration and Roles of Each Element
10.2.1 Beer’s Cybernetic Model
10.2.2 Ashby’s Law of Requisite Variety
10.2.3 Probabilistic Risk Assessment Studies
10.2.4 Rasmussen’s Human Behavior Types
10.2.5 Case Studies of Accident for Different Industries
10.2.6 Training Methods and Role of Advisors
10.2.6.1 Use of Advisors
10.2.7 Simulation of Processes and Its Value
10.2.8 Summary
10.2.8.1 Organizational Dynamic Model
10.2.8.2 Ashby’s Law
10.2.8.3 Probabilistic Risk Assessment
10.2.8.4 Rasmussen’s Human Behavioral Models
10.2.8.5 Accident Case Studies
10.2.8.6 Training Methods
10.2.8.7 Simulation Processes
Chapter 11 Use of Simulation for Different Operations
11.1 Introduction
11.2 Simulators
11.3 Simulations
11.4 Future Uses: Decision-Making
11.5 Summary
Chapter 12 Training Approaches for Management
12.1 Introduction
12.2 Education
12.3 Technical Tools for Managers
12.4 Conclusions
Chapter 13 Investment in Safety
13.1 Introduction
13.2 Managing for Shareholder Value
13.3 Brief Overview of the Principles of MSV
13.4 Using the J-Value to Estimate the Level of Investment Needed for Safety
13.4.1 Formulation of the J-Value
13.4.2 Limiting Risk Multiplier
13.4.3 Application of the J-Value
13.4.3.1 J-Value Analysis
13.5 Conclusion
Chapter 14 Conclusions and Comments
14.1 Introduction
14.2 Analytical Elements
14.3 Conclusion
Appendix: Admiral Rickover’s Management Principles
References
Index
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