Making Systems Safer contains the papers presented at the eighteenth annual Safety-critical Systems Symposium, held at Bristol, UK, in February 2010. The Symposium is for engineers, managers and academics in the field of system safety, across all industry sectors, so the papers making up this volume offer a wide-ranging coverage of current safety topics, and a blend of academic research and industrial experience. They include both recent developments in the field and discussion of open issues that will shape future progress. The first paper reflects a tutorial – on Formalization in Safety Cases – held on the first day of the Symposium. The subsequent 15 papers are presented under the headings of the Symposium’s sessions: Perspectives on Systems Safety, Managing Safety-Related Projects, Transport Safety, Safety Standards, Safety Competencies and Safety Methods. The book will be of interest to both academics and practitioners working in the safety-critical systems arena.

A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a simpler, analog world, have changed very little over the years. In this groundbreaking book, Nancy Leveson proposes a new approach to safety—more suited to today's complex, sociotechnical, software-intensive world—based on modern systems thinking and systems theory. Revisiting and updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate, Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP), then shows how the new model can be used to create techniques for system safety engineering, including accident analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems. She applies the new techniques to real-world events including the friendly-fire loss of a U.S. Blackhawk helicopter in the first Gulf War; the Vioxx recall; the U.S. Navy SUBSAFE program; and the bacterial contamination of a public water supply in a Canadian town. Leveson's approach is relevant even beyond safety engineering, offering techniques for “reengineering” any large sociotechnical system to improve safety and manage risk.

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

The contributions to this book are the invited papers presented at the fifth annual Safety-critical Systems Symposium. They cover a broad spectrum of issues affecting safety, from a philosophical appraisal to technology transfer, from requirements analysis to assessment, from formal methods to artificial intelligence and psychological aspects. They touch on a number of industry sectors, but are restricted to none, for the essence of the event is the transfer of lessons and technologies between sectors. All address practical issues and of fer useful information and advice. Contributions from industrial authors provide evidence of both safety con sciousness and safety professionalism in industry. Smith's on safety analysis in air traffic control and Rivett's on assessment in the automotive industry are informative on current practice; Frith's thoughtful paper on artificial intelli gence in safety-critical systems reflects an understanding of questions which need to be resolved; Tomlinson's, Alvery's and Canning's papers report on collaborative projects, the first on results which emphasise the importance of human factors in system development, the second on the development and trial of a comprehensive tool set, and the third on experience in achieving tech nology transfer - something which is crucial to increasing safety.

This important and timely book contains vital information for all developers working with C, whether in high-integrity areas or not, who need to produce reliable and effective software.

Building Safe Systems in Aviation provides a single source for those who need to progress beyond current models of Crew Resource Management (CRM) to developing safe systems in critical industries. Although the primary focus is on airline pilots, the principles apply to all sectors of aviation, particularly maintenance and cabin crew, as well as other high-risk industries. It systematically sets out the context of CRM and safe systems, the conduct of training, the resources needed by the facilitator and the processes required for the measurement of outcomes. Part One reviews the development of the human factors/CRM domain and examines the concepts of risk and safety. Part Two, primarily for new instructors, gives a guide to training delivery and also considers non-classroom situations, the role of debriefing, facilitation and the design of human factors courses. Part Three examines the measurement of training effectiveness, the design and implementation of behavioural markers and standardizing assessors. It concludes by looking at some of the broader issues associated with the management of CRM. The book's readership includes those who design, deliver or manage CRM and safety-related training within airlines and other companies.

This first-of-its-kind resource offers a broad and detailed understanding of software systems engineering from both security and safety perspectives. Addressing the overarching issues related to safeguarding public data and intellectual property, the book defines such terms as systems engineering, software engineering, security, and safety as precisely as possible, making clear the many distinctions, commonalities, and interdependencies among various disciplines. You explore the various approaches to risk and the generation and analysis of appropriate metrics. This unique book explains how processes relevant to the creation and operation of software systems should be determined and improved, how projects should be managed, and how products can be assured. You learn the importance of integrating safety and security into the development life cycle. Additionally, this practical volume helps identify what motivators and deterrents can be put in place in order to implement the methods that have been recommended.

This report takes stock of recent developments and initiatives to meet increasingly ambitious road safety targets, and constitutes a major international review of progress in developing Safe System approaches, now adopted in a small number of countries.

The continued lack of access to adequate amounts of safe drinking water is one of the primary causes of infant morbidity and mortality worldwide and a serious situation which governments, international agencies and private organizations are striving to alleviate. Barriers to providing safe drinking water for rural areas and small communities that must be overcome include the financing and stability of small systems, their operation, and appropriate, cost-effective technologies to treat and deliver water to consumers. While we know how to technically produce safe drinking water, we are not always able to achieve sustainable safe water supplies for small systems in developed and developing countries. Everyone wants to move rapidly to reach the goal of universal safe drinking water, because safe water is the most fundamental essential element for personal and social health and welfare. Without safe water and a safe environment, sustained personal economic and cultural development is impossible. Often small rural systems are the last in the opportunity line. Safe Drinking Water in Small Systems describes feasible technologies, operating procedures, management, and financing opportunities to alleviate problems faced by small water systems in both developed and developing countries. In addition to widely used traditional technologies this reference presents emerging technologies and non-traditional approaches to water treatment, management, sources of energy, and the delivery of safe water.

This book offers a new, practical approach to healthcare reform. Departing from the priorities applied in traditional approaches, it instead assesses – both theoretically and practically – the successful lessons learned in other safety-critical industries, and applies them to healthcare settings. The authors focus on the importance of human factors and performance measures to establish proactive, systematic methods for healthcare system design. This approach helps to identify potential hazards before accidents occur, enhancing patient safety. In addition, the book details the new approach on the basis of real-world applications in the NHS and insights from NHS staff. Case studies and results are presented, demonstrating the significant improvements that can be achieved in risk reduction and safety culture. Lastly, the book outlines what steps healthcare organisations need to take in order to successfully adopt this new approach. The approach and experiential learning is brought together through the development of a new holistic patient safety education syllabus.