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Engineering a Safer World:Systems Thinking Applied to Safety

Cover Image Copyright Year: 2012
Author(s): Leveson, N.
Publisher: MIT Press
Content Type : Books & eBooks
Topics: General Topics for Engineers (Math, Science & Engineering)
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Abstract

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 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.

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      Front Matter

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): i - xx
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Half Title, Engineering Systems, Title, Copyright, Dedication, Contents, Series Foreword, Preface View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Foundations

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 1
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Why Do We Need Something Different?

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 3 - 6
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Questioning the Foundations of Traditional Safety Engineering

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 7 - 60
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Confusing Safety with Reliability, Modeling Accident Causation as Event Chains, Limitations of Probabilistic Risk Assessment, The Role of Operators in Accidents, The Role of Software in Accidents, Static versus Dynamic Views of Systems, The Focus on Determining Blame, Goals for a New Accident Model View full abstract»

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      Systems Theory and Its Relationship to Safety

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 61 - 72
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: An Introduction to Systems Theory, Emergence and Hierarchy, Communication and Control, Using Systems Theory to Understand Accidents, Systems Engineering and Safety, Building Safety into the System Design View full abstract»

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      Stamp: An Accident Model Based on Systems Theory

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 73
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      A Systems-Theoretic View of Causality

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 75 - 102
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Safety Constraints, The Hierarchical Safety Control Structure, Process Models, STAMP, A General Classification of Accident Causes, Applying the New Model View full abstract»

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      A Friendly Fire Accident

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 103 - 167
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Background, The Hierarchical Safety Control Structure to Prevent Friendly Fire Accidents, The Accident Analysis Using STAMP, Conclusions from the Friendly Fire Example View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Using STAMP

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 169
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Engineering and Operating Safer Systems Using STAMP

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 171 - 180
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Why Are Safety Efforts Sometimes Not Cost-Effective?, The Role of System Engineering in Safety, A System Safety Engineering Process View full abstract»

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      Fundamentals

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 181 - 209
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Defining Accidents and Unacceptable Losses, System Hazards, System Safety Requirements and Constraints, The Safety Control Structure View full abstract»

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      STPA: A New Hazard Analysis Technique

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 211 - 249
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Goals for a New Hazard Analysis Technique, The STPA Process, Identifying Potentially Hazardous Control Actions (Step 1), Determining How Unsafe Control Actions Could Occur (Step 2), Human Controllers, Using STPA on Organizational Components of the Safety Control Structure, Reengineering a Sociotechnical System: Pharmaceutical Safety and the Vioxx Tragedy, Comparison of STPA with Traditional Hazard Analysis Techniques, Summary View full abstract»

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      Safety-Guided Design

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 251 - 306
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: The Safety-Guided Design Process, An Example of Safety-Guided Design for an Industrial Robot, Designing for Safety, Special Considerations in Designing for Human Controllers, Summary View full abstract»

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      Integrating Safety into System Engineering

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 307 - 347
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: The Role of Specifications and the Safety Information System, Intent Specifications, An Integrated System and Safety Engineering Process View full abstract»

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      Analyzing Accidents and Incidents (CAST)

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 349 - 390
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: The General Process of Applying STAMP to Accident Analysis, Creating the Proximal Event Chain, Defining the System(s) and Hazards Involved in the Loss, Documenting the Safety Control Structure, Analyzing the Physical Process, Analyzing the Higher Levels of the Safety Control Structure, A Few Words about Hindsight Bias and Examples, Coordination and Communication, Dynamics and Migration to a High-Risk State, Generating Recommendations from the CAST Analysis, Experimental Comparisons of CAST with Traditional Accident Analysis, Summary View full abstract»

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      Controlling Safety during Operations

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 391 - 414
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Operations Based on STAMP, Detecting Development Process Flaws during Operations, Managing or Controlling Change, Feedback Channels, Using the Feedback, Education and Training, Creating an Operations Safety Management Plan, Applying STAMP to Occupational Safety View full abstract»

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      Managing Safety and the Safety Culture

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 415 - 443
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Why Should Managers Care about and Invest in Safety?, General Requirements for Achieving Safety Goals, Final Thoughts View full abstract»

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      SUBSAFE: An Example of a Successful Safety Program

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 445 - 461
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: History, SUBSAFE Goals and Requirements, SUBSAFE Risk Management Fundamentals, Separation of Powers, Certification, Audit Procedures and Approach, Problem Reporting and Critiques, Challenges, Continual Training and Education, Execution and Compliance over the Life of a Submarine, Lessons to Be Learned from SUBSAFE View full abstract»

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      Epilogue

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 463 - 464
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Appendixes

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 465
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Definitions

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 467 - 468
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      The Loss of a Satellite

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 469 - 493
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: The Physical Process, Description of the Proximal Events Leading to the Loss, Physical Process and Automated Controller Failures and Dysfunctional Interactions, Launch Site Operations, Air Force Launch Operations Management, Software/System Development of the Centaur Flight Control System, Quality Assurance (QA), Developer Testing Process, Independent Verification and Validation (IV & V), Systems Engineering, Prime Contractor Project Management, Defense Contract Management Command (DCMC), Air Force Program Office View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      A Bacterial Contamination of a Public Water Supply

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 495 - 516
      Copyright Year: 2012

      MIT Press eBook Chapters

      This chapter contains sections titled: Proximate Events at Walkerton, System Hazards, System Safety Constraints, and Control Structure, Physical Process View of the Accident, First-Level Operations, Municipal Government, Provincial Regulatory Agencies (Ministries), Provincial Government, The Structural Dynamics, Addendum to the Walkerton Accident Analysis View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      A Brief Introduction to System Dynamics Modeling

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 517 - 519
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      References

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 521 - 529
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»

    • Full text access may be available. Click article title to sign in or learn about subscription options.

      Index

      Leveson, N.
      Engineering a Safer World:Systems Thinking Applied to Safety

      Page(s): 531 - 534
      Copyright Year: 2012

      MIT Press eBook Chapters

      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 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. View full abstract»




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