If human errors are assumed as crimes in a safety culture: A lifeworld analysis of a rail crash

2009 ◽  
Vol 62 (9) ◽  
pp. 1267-1287 ◽  
Author(s):  
Nobuyuki Chikudate
Keyword(s):  
Safety Culture ◽  
Unintended Consequences ◽  
The West ◽  
Human Errors ◽  
Railway Company ◽  
Learning Practices ◽  
Train Driver

This study reanalyses the commuter train incident that involved the West Japan Railway Company (JR West). The incident, which occurred on 25 April 2005, claimed 107 lives (passengers and the train driver) and injured 562 passengers. The delay in using the brake and the train driver’s inattention generated confusion and serious errors. The train driver’s inattentiveness may be attributed to his grave concern over reporting personal mistakes to company authorities as it is mandatory for erring JR West crew members to go through ‘learning practices’. The phenomenological analyses showed how the unintended consequences of such learning practices played a key role in the train incident. This study also draws on Foucault’s concepts on discipline to analyse the learning practices in JR West, and employs the concept of collective myopia to account for the reasoning of JR West managers.

Characteristics of Train Stations Where Railway Suicides Have Occurred and Locations Within the Stations

Crisis ◽  
2021 ◽  
pp. 1-6
Author(s):  
Hajime Sueki
Keyword(s):  
Regression Model ◽  
Poisson Regression ◽  
Psychiatric Hospitals ◽  
Blind Spot ◽  
Outcome Variable ◽  
Poisson Regression Model ◽  
Railway Company ◽  
Model Study ◽  
Train Driver ◽  
Railway Suicide

Abstract. Background: To devise effective railway suicide countermeasures, it is necessary to identify stations where suicide is likely to occur. Aim: We explored the characteristics of stations where railway suicides have occurred and locations within the stations. Method: (Study 1) Using suicide data from between April 2014 and September 2019 provided by a major railway company in Japan, station-specific suicide was modeled as an outcome variable in a multivariate Poisson regression model. (Study 2) With railway company staff, we visited stations where suicide frequently occurs and conducted fieldwork. Results: (Study 1) Our estimation using a Poisson regression model revealed that railway suicides were more frequent when stations were serviced by passing trains, had a large number of passengers, and were located near psychiatric hospitals. (Study 2) Of 50 suicides, 48.0% occurred in front of benches or waiting rooms, 26.0% occurred at the front end of the platform, 24.0% occurred at the entrance to the platform, and 22.0% occurred at a blind spot for the train driver. Limitations: All data were provided by one railway company in Japan, limiting the generalizability of the results. Conclusion: Stations where suicide occurs frequently have distinct characteristics. Focusing on suicide hotspots may aid suicide prevention.

scholarly journals Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy

2017 ◽  
Vol 24 (5) ◽  
pp. 958-963 ◽  
Author(s):  
Richard Schreiber ◽  
Dean F Sittig ◽  
Joan Ash ◽  
Adam Wright
Keyword(s):  
Laboratory Tests ◽  
Clinical Laboratory ◽  
Unintended Consequences ◽  
New Order ◽  
Laboratory System ◽  
Order Entry ◽  
Timely Manner ◽  
Human Errors ◽  
Order Management ◽  
User Actions

Abstract In this report, we describe 2 instances in which expert use of an electronic health record (EHR) system interfaced to an external clinical laboratory information system led to unintended consequences wherein 2 patients failed to have laboratory tests drawn in a timely manner. In both events, user actions combined with the lack of an acknowledgment message describing the order cancellation from the external clinical system were the root causes. In 1 case, rapid, near-simultaneous order entry was the culprit; in the second, astute order management by a clinician, unaware of the lack of proper 2-way interface messaging from the external clinical system, led to the confusion. Although testing had shown that the laboratory system would cancel duplicate laboratory orders, it was thought that duplicate alerting in the new order entry system would prevent such events.

A Hybrid Analysis Method for Train Driver Errors in Railway Systems

2020 ◽  
pp. 176-202
Author(s):  
Mohammed Manar Rekabi ◽  
Yiliu Liu
Keyword(s):  
Process Analysis ◽  
Quantitative Risk Assessment ◽  
Comprehensive Overview ◽  
Human Errors ◽  
Railway Systems ◽  
Train Control ◽  
Driver Performance ◽  
Train Driver ◽  
Level 2

The main objective of this chapter is to analyze safety in railway systems through studying and understanding the train drivers' tasks and their common errors. Different approaches to classifying and analyzing driver errors are reviewed, as well the factors that affect driver performance. A comprehensive overview of the systems theoretic process analysis (STPA) method is presented, along with how it could be applied for controllers and humans. Quantitative risk assessment, along with some methods for quantifying human errors, are overviewed, and a Bayesian network is selected to study the effects of the identified driver errors. A case study aims to present a detailed quantitative safety analysis at European Train Control System (ETCS) system Levels 1 and Level 2, including driver errors. The STPA and Bayesian methods are combined to identify the hazards and quantify the probabilities of hazards when trains fail to stop at red signals.

scholarly journals What Have We Done? Law, Responsibility and Technologies

2020 ◽  
Vol 2 (1) ◽  
pp. 45-56
Author(s):  
Richard Mohr
Keyword(s):  
Ethical Judgment ◽  
Unintended Consequences ◽  
The West ◽  
New Developments ◽  
Probative Value ◽  
Technological Practice ◽  
The Social ◽  
Technological Developments ◽  
The Relationship ◽  
Culture Technology

The relationship between humans and the environment is becoming unsustainable. Technologies mediate this relationship. In turn, technology is a product of dense cultural phenomena, from research institutions to capitalism, from ethics to cosmology. This paper investigates the ‘cosmotechnics’ of technical interactions with the environment and explores the sources of these social, ethical and environmental problems. The disconnect between humans and nature is traced to the roots of Western culture, while alternative views have emerged within the West and through its awareness of other cultures. Technology in the West betrays a titanic urge to overcome nature. Since all technologies mesh with their immediate and global environment, invention arises from the interaction between assemblages of humans, machines and the environment. All contribute incrementally to new developments, which are not conscious projects fulfilling specific intentions, but evolving scenarios. Without any clear intentional drive determining technological developments—nor any clear distinction between intended and unintended consequences—the concept of intention has little probative value. Instead, we approach the ethical judgment of outcomes from the viewpoint of responsibility. The social milieu and its actors are to be held to account for the consequences, regardless of intentions. The paper identifies a malaise arising when the products of labour are split from an awareness of agency. This alienation opens up a misrecognition basic to unsustainable technologies. It operates at three discernible levels: technology split from culture; technology split from ethics and values; and theory split from technological practice. Solutions are sought through overcoming each of these gaps.

scholarly journals IMPLEMENTATION OF THE THINK-TALK-WRITE (TTW) STRATEGY TO IMPROVE UNDERSTANDING OF MATHEMATICS CONCEPTS IN SMP NEGERI 1 BANGKO

2021 ◽  
Vol 10 (4) ◽  
pp. 852
Author(s):  
Antonius Nainggolan
Keyword(s):  
Action Research ◽  
Class Action ◽  
Learning System ◽  
The West ◽  
Mathematical Concepts ◽  
Face To Face ◽  
Is Research ◽  
Learning Practices ◽  
Classroom Action Research

During the COVID-19 pandemic, the learning process, which is usually carried out face-to-face in front of the class, can no longer be carried out, resulting in the change of the learning system to online. This study aims to improve students' understanding of mathematical concepts at SMP Negeri 1 Bangko with the research method used is Classroom Action Research (CAR). CAR comes from the west known as Classroom Action Research (CAR). As stated by Arikunto, CAR is research conducted in the classroom with the aim of improving or improving the quality of learning practices. The results obtained about the understanding of students' concepts before conducting the class action research showed an average class of 63.50 with the number of students who completed 13 people with a classical percentage of 42%. In the first cycle, the average class obtained was 69.83 with a total of 20 people who completed with a percentage of the classical number of 65%. The increase occurred in the second cycle with an average class of 81 with the number of students who completed 31 people with a percentage of the classical number of 100% so that it can be concluded that using the Think Talk Write (TTW) strategy can improve understanding of mathematical concepts.

From Solution to Problem

2019 ◽  
pp. 163-193
Author(s):  
Peter C. Caldwell
Keyword(s):  
Social Policy ◽  
Social Science ◽  
Welfare State ◽  
Welfare States ◽  
Unintended Consequences ◽  
Western World ◽  
Aid Workers ◽  
The West ◽  
The Social ◽  
The Welfare State

The 1970s and 1980s saw two important changes in the West German discussion of the welfare state. First, global trade put direct economic pressure on expensive welfare states in the western world. Second, the social science discussion of the welfare state shifted to a language of systems, which no longer viewed the welfare state as a tool of state or society, but asked about how systems of social policy could have unintended consequences—how social solutions could pose their own problems. Young Marxists, breaking with the SPD, questioned the possibility of a welfare state that could aid workers under capitalism; conservative state theorists questioned whether democracy, with its demands for state solutions, could paralyze the state. The result was a more complex reading of how the modern word created complex challenges for individuals and states alike, especially well articulated in the work of Kaufmann and Luhmann.

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