Preface |
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xv | |
Acknowledgements |
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xix | |
About the Author |
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xxi | |
Acronyms |
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xxiii | |
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1 | (16) |
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1 | (3) |
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4 | (1) |
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The Importance of Operator and Maintenance Error |
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5 | (2) |
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7 | (2) |
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9 | (1) |
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Slips, Lapses, Mistakes and Violations |
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10 | (1) |
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Assessing the Probability of Operator Errors |
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11 | (2) |
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The Need for an Interdisciplinary Approach |
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13 | (1) |
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What Should We Do about Error Potential? |
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13 | (2) |
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Data Collection for This Book |
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15 | (1) |
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16 | (1) |
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Chapter 2 Models of Operator Error |
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17 | (8) |
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The Skills--Rules--Knowledge Model |
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19 | (2) |
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21 | (1) |
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21 | (1) |
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Knowledge-Based Processing |
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22 | (1) |
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Status of the Skills--Rules--Knowledge Model |
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22 | (1) |
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23 | (1) |
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23 | (2) |
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Chapter 3 Hindrances and Inability to Function |
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25 | (6) |
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25 | (1) |
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Error-Reduction Measures for Absence from Work Location |
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26 | (1) |
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26 | (1) |
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27 | (1) |
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Error-Reduction Measures for Incapacitation |
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27 | (1) |
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27 | (1) |
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Error-Reduction Measures for Distraction |
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28 | (1) |
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28 | (1) |
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Error-Reduction Measures for Attention Failure |
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29 | (1) |
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29 | (1) |
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Error-Reduction Measures for Overload |
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29 | (1) |
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Priority Error and Focus Error |
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30 | (1) |
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30 | (1) |
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Chapter 4 Errors in Observation |
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31 | (4) |
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Potential Operational Input Overlooked |
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31 | (1) |
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Complex or Unrecognisable Input |
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31 | (1) |
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32 | (1) |
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Ambiguity and Misleading Signals |
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32 | (1) |
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33 | (1) |
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Failures of Instruments and Alarms |
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34 | (1) |
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34 | (1) |
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Chapter 5 Errors in Performing Standard Procedures: Rule-Based Operation |
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35 | (16) |
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The Process of Rule-Based Operation |
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35 | (3) |
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38 | (1) |
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Thought Processes in Procedure Execution |
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38 | (2) |
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Error Modes in Carrying Out Procedures |
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40 | (1) |
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Causes of Errors in Carrying Out Procedures---Following Cues |
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41 | (1) |
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Causes of Errors in Carrying Out Procedures---Omission |
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42 | (2) |
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Errors in Procedure Execution---Wrong Procedure |
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44 | (3) |
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Errors in Procedure Execution---Too Much or Too Little |
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47 | (1) |
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Errors in Procedure Execution---Too Long or Too Short Duration |
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48 | (1) |
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Errors in Action Performance |
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48 | (2) |
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Risk-Reduction Measures for Errors in Executing Procedures |
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50 | (1) |
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50 | (1) |
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Chapter 6 Operator Error in the Field |
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51 | (8) |
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52 | (1) |
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Errors in Procedure Execution---Wrong Object or Material |
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53 | (4) |
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57 | (1) |
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57 | (2) |
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Chapter 7 Knowledge and Ignorance in Plant Operation |
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59 | (20) |
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Knowledge-Based Operation under Modern Conditions |
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61 | (1) |
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62 | (1) |
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62 | (1) |
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Knowledge, Belief and Judgement |
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63 | (3) |
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A Little Knowledge Can Be Dangerous |
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66 | (1) |
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66 | (1) |
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67 | (3) |
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Knowledge of Plant Physics |
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70 | (1) |
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An Example of Accident Physics---Momentum |
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71 | (3) |
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Knowledge-Based Operating Errors |
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74 | (2) |
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Predicting Knowledge-Based Errors |
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76 | (1) |
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77 | (2) |
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Chapter 8 Errors in Supervisory Control |
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79 | (12) |
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Errors in Supervisory Control---Checking Values |
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80 | (1) |
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Checking a Complex Precondition |
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81 | (1) |
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Responding to Abnormal Conditions |
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82 | (1) |
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Operations with Failed Instruments |
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83 | (1) |
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Improvisation and Operation under Abnormal Conditions |
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84 | (2) |
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86 | (1) |
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Operator Performance under Abnormal Conditions |
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87 | (1) |
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Operator Errors in Abnormal Situations |
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88 | (1) |
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Reducing Error in Abnormal Situations |
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89 | (1) |
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89 | (2) |
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Chapter 9 Emergency Response and Disturbance Control |
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91 | (12) |
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92 | (4) |
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Errors in Emergency Response |
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96 | (3) |
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Analysis for Emergency Response |
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99 | (1) |
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Errors in Emergency Response |
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100 | (1) |
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Reducing the Potential for Error in Emergency Response |
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100 | (1) |
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101 | (2) |
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Chapter 10 Diagnosis of Plant Disturbances |
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103 | (8) |
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105 | (3) |
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Immediate Associative Recognition |
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105 | (1) |
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Respond First, Then Explain |
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106 | (1) |
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106 | (1) |
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Assumption of Repetition of an Earlier Disturbance |
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107 | (1) |
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Brain Searching and Brainstorming |
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107 | (1) |
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108 | (1) |
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108 | (1) |
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109 | (1) |
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109 | (1) |
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110 | (1) |
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Reducing Error Potential in Diagnosis |
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110 | (1) |
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110 | (1) |
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Chapter 11 Errors in Decision Making and Planning |
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111 | (12) |
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Risk Taking and Risk Blindness |
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113 | (2) |
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115 | (1) |
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116 | (1) |
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Risk Taking and Risk Blindness in Maintenance |
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117 | (2) |
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119 | (1) |
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Institutionalised Risk Taking |
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120 | (1) |
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Assessing Risk-Taking Hazards |
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121 | (1) |
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Reducing the Potential for Risk-Taking Errors |
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122 | (1) |
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122 | (1) |
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Chapter 12 Infractions and Violations |
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123 | (8) |
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Housekeeping and Everyday Hazards |
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123 | (1) |
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Unauthorised Improvisations |
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123 | (2) |
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125 | (1) |
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125 | (3) |
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128 | (1) |
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128 | (1) |
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128 | (1) |
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129 | (1) |
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129 | (2) |
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Chapter 13 Management Error |
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131 | (22) |
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Errors of Omission in Plant Management |
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132 | (1) |
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Inadequacies in Safety Management Procedures |
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132 | (1) |
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133 | (1) |
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Mistrust of Safety Analysis and Safety Management |
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133 | (3) |
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Lack of Knowledge of Process Safety |
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136 | (1) |
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137 | (2) |
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Patching Up and Making Do |
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139 | (2) |
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Downsizing and Outsourcing |
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141 | (2) |
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Optimum Safety? Problems with the ALARP Principle |
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143 | (1) |
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Pity the Poor Plant Manager |
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144 | (1) |
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144 | (1) |
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145 | (2) |
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147 | (1) |
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147 | (2) |
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High-Integrity Organisations |
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149 | (1) |
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Assessment of Management Error? |
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150 | (1) |
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151 | (2) |
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Chapter 14 Communication Errors |
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153 | (8) |
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Communication Error Types |
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154 | (1) |
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155 | (1) |
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Drawings as a Means of Communication |
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155 | (1) |
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156 | (1) |
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156 | (1) |
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Permit to Work as a Source of Plant State Knowledge |
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157 | (2) |
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Safeguards against Communication Errors |
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159 | (1) |
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159 | (2) |
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Chapter 15 Error Syndromes |
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161 | (18) |
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162 | (1) |
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162 | (3) |
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165 | (1) |
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165 | (1) |
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Omission Due to Distraction |
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165 | (1) |
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166 | (1) |
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166 | (1) |
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Overlooking a Precondition or Latent Hazard |
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167 | (1) |
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Too Narrow Basis for a Decision: Tunnel Vision |
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168 | (1) |
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168 | (1) |
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169 | (1) |
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The Forget--Remember Syndrome |
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169 | (1) |
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Repairing the Wrong Item, Dismantling the Wrong Equipment |
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170 | (1) |
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171 | (1) |
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172 | (1) |
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Reinterpretation of Instrument Failure as Normal |
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173 | (1) |
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174 | (1) |
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Ignoring `Nuisance Alarms' |
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175 | (1) |
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Switching Off Safety Systems |
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175 | (1) |
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Personalised Emergency Procedures |
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175 | (1) |
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175 | (1) |
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175 | (1) |
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176 | (1) |
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Using Safety Devices as Controllers |
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177 | (1) |
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177 | (1) |
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178 | (1) |
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Using Error Syndrome Patterns in Error Analysis |
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178 | (1) |
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178 | (1) |
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179 | (16) |
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179 | (3) |
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182 | (4) |
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Design Errors Due to Lack of Knowledge |
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186 | (4) |
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190 | (2) |
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192 | (1) |
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193 | (2) |
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Chapter 17 Errors in Procedures |
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195 | (8) |
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Writing Operating Procedures |
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195 | (2) |
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197 | (1) |
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198 | (1) |
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198 | (1) |
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Checking Written Procedures |
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199 | (1) |
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199 | (3) |
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Reducing Procedural Error |
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202 | (1) |
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202 | (1) |
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Chapter 18 Identifying Human Error Potential |
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203 | (22) |
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204 | (1) |
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205 | (2) |
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207 | (1) |
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207 | (1) |
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Action Error Cause Analysis |
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207 | (4) |
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Risk Analysis of the Errors |
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211 | (1) |
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211 | (1) |
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Example of Action Error Analysis---Removing a Scraper from a Scraper Trap (Pig Receiver) |
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212 | (10) |
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Risk Reduction for the Scraper Trap Operation |
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222 | (1) |
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Tracking of Operational State against a Mental Model |
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223 | (1) |
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Observations on the Example Analysis |
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223 | (1) |
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224 | (1) |
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Chapter 19 Error Probabilities |
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225 | (40) |
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Why Do We Need to Quantify Error Probability? |
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225 | (1) |
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Risk Determination Based on Statistics |
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226 | (1) |
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Detailed Error Probability Determination |
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227 | (3) |
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Frequency of Latent Hazard Events |
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230 | (1) |
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230 | (1) |
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Anchor Point Data---Examples |
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231 | (13) |
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An Error of Omission---Too Late Check |
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231 | (1) |
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Premature Termination of Production |
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232 | (1) |
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232 | (1) |
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Omission---Forgetting to Close Manifold Valves and Overlooking the Signs of Overflow |
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233 | (1) |
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Omission---Overlooking a Level Alarm |
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234 | (1) |
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Wrong Object---Confusion of the Item to Be Operated |
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235 | (1) |
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Wrong Object---Maintenance of the Wrong Item |
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236 | (1) |
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237 | (1) |
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Too Late---Tank Truck Filling |
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237 | (1) |
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Too Fast---Rough Operation |
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238 | (1) |
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238 | (1) |
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Overlooking Low Suction Pressure |
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239 | (1) |
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Failure to Respond in Time to a Power Failure |
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239 | (1) |
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Restarting Plant Operation with Tests Incomplete |
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239 | (1) |
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Failure to Remove Trip Bypasses |
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239 | (1) |
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240 | (1) |
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240 | (1) |
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Risk Taking in Construction |
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241 | (1) |
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241 | (1) |
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Driveaway without Decoupling a Hose, an Oxygen Plant and an Ammonia Plant |
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241 | (1) |
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Walking Away with Tank Draining |
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242 | (1) |
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Forklift Truck Driving Too Fast or Too Unstable Load |
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242 | (1) |
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Piling on the Gas, Gasoline Transfer |
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242 | (1) |
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Erroneous Closure of a Drain Line |
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242 | (1) |
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Performance-Shaping Factors and Error Causes |
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243 | (1) |
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Simulators as a Source of Error Probability Data |
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244 | (1) |
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Summary of Anchor Point Frequencies |
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244 | (14) |
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Using the Human Error Probability Data |
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258 | (4) |
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262 | (1) |
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263 | (1) |
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264 | (1) |
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Chapter 20 Examples of Human Error Analysis |
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265 | (16) |
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Action Error Analysis for Fuel Transfer to a Tank |
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265 | (5) |
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270 | (2) |
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Task Risk Analysis for Equipment Isolation |
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272 | (7) |
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279 | (2) |
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Chapter 21 Human Error Risk Reduction |
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281 | (6) |
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Operator Error Minimisation |
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281 | (1) |
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Training for Reliable and Safe Operation |
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281 | (1) |
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281 | (1) |
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282 | (1) |
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283 | (1) |
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283 | (2) |
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285 | (1) |
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286 | (1) |
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287 | (2) |
Bibliography |
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289 | (2) |
Index |
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291 | |