Abstract
After a serious accident we always ask ourselves an unnerving question: is it really possible that an involuntary human error can cause a disaster of these dimensions?
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Notes
- 1.
M. Catino, “Incidenti tecnologici nel trasporto ferroviario,” Ergonomia, n. 1, pp. 36–51, 2006.
- 2.
Cf., for example J. REASON, Human Error, Cambridge University Press, London 1990.
- 3.
R. Westrun, Social Factors in Safety Critical Systems, in F. Redmill – F.- J. Rajan (edited by), Human Factors in Safety Critical Systems, Butterworth – Heinemann, London 1997.
- 4.
M. Catino, Organizational Myopia: Problems of Rationality and Foresight in Organizations, Cambridge University Press, 2013.
- 5.
M. Catino, op.cit., 2013.
- 6.
J. Rasmussen, Safety Control and Risk Management, in NPPCI Specialists’ Meeting on the Human Factor Feedback in Nuclear Power, Implication of operating Experience on System Analysis, Design and Operation, L. Hansson and B. Andersen, ed. Risø National Laboratory, Roskilde, 1987 and also J. Reason, Human Error, Cambridge University Press, London 1990.
- 7.
M. Catino, op.cit., 2013.
- 8.
B. Turner – N. Pidgeon, Man-Made Disasters, 2nd ed., Butterworth – Heinemann, Oxford 1997, C. Perrow, Normal accidents: Living with High-Risk Technologies, Basic Books, New York, 1984, P. Shivrastava, Bhopal: Anatomy of a crisis, Ballinger Publishing Camp., Cambridge 1887, D. Vaughan, “Autonomy, interdependence and Social Control: NASA and the Space Shuttle Challenger,” Administrative Science Quarterly, 35 (2) pp. 225–257, 1990, D. Vaughan, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, University of Chicago Press, Chicago, 1996.
- 9.
M. Catino, op.cit., 2013.
- 10.
J. Reason, op.cit., 1997.
- 11.
M. Catino, op.cit., 2013.
- 12.
Since then, from indication given by the US NTSB, the commission of inquiry, it has become obligatory to use strobe lights even during taxiing.
- 13.
M. Catino, op.cit., 2006.
- 14.
M. Catino, op.cit., 2006.
- 15.
There was a bar, in fact, but it had been disactivated years before.
- 16.
Here again, it is interesting to note that an anti-intrusion indicator had been present on the old model of console used in the control tower of Linate.
- 17.
M. Catino, op.cit., 2006.
- 18.
M. Catino, op.cit., 2006.
- 19.
M. Catino, op.cit., 2006.
- 20.
M. Catino, op.cit., 2006.
- 21.
S. Nashef, “What is a near miss?,” The Lancet, 361, pp. 180–181, 2003.
- 22.
This was at the heart of the severe analysis that Feynman brought in front of the Government Inquiry into the disaster of the Challenger.
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D’Errico, F., Casa, M.D. (2016). The Analysis of Accidents Using a Multi-Level Approach: Organizational Accidents. In: The Sequence of Event Analysis in Criminal Trials. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-47898-1_5
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