Engineering a Safer World Systems Thinking Applied to Safety
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...
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| Main Author | |
|---|---|
| Format | eBook Book |
| Language | English |
| Published |
Cambridge
MIT Press
2012
The MIT Press |
| Edition | 1 |
| Series | Engineering Systems |
| Subjects | |
| Online Access | Get full text |
| ISBN | 0262016621 9780262016629 0262533693 9780262533690 9780262298247 0262298244 |
| DOI | 10.7551/mitpress/8179.001.0001 |
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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. |
|---|---|
| AbstractList | 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. 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. 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. 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, the author 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, the author 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. A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. |
| Author | Leveson, Nancy G |
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| Copyright | 2012 Massachusetts Institute of Technology 2011 2012 MIT This content is available without a subscription. It may not be altered in any way and proper attribution is required. https://creativecommons.org/licenses/by-sa/4.0/legalcode |
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| Snippet | Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a... A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has... A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has... 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 new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. |
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| SubjectTerms | cybernetics Cybernetics and systems theory Engineering Engineering Principles Engineering: general General Engineering & Project Administration General Topics for Engineers Industrial Health & Safety Industrial safety Information theory Intermediate technology Reference, Information and Interdisciplinary subjects Research and information: general safety System safety Systems Science & Engineering Technology & Engineering Technology, Engineering, Agriculture, Industrial processes Technology: general issues |
| SubjectTermsDisplay | Electronic books. Industrial safety. System safety. |
| Subtitle | Systems Thinking Applied to Safety |
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| TableOfContents | Front Matter
Preface
Table of Contents
1. Why Do We Need Something Different?
2. Questioning the Foundations of Traditional Safety Engineering
3. Systems Theory and its Relationship to Safety
Part II. STAMP: An Accident Model Based on Systems Theory
4. A Systems-Theoretic View of Causality
5. A Friendly Fire Accident
Part III. Using STAMP
6. Engineering and Operating Safer Systems Using STAMP
7. Fundamentals
8. STPA: A New Hazard Analysis Technique
9. Safety-Guided Design
10. Integrating Safety into System Engineering
11. Analyzing Accidents and Incidents (CAST)
12. Controlling Safety during Operations
13. Managing Safety and the Safety Culture
14. SUBSAFE: An Example of a Successful Safety Program
Epilogue
Appendices
References
Index Chapter 8. STPA: A New Hazard Analysis Technique -- 8.1 Goals for a New Hazard Analysis Technique -- 8.2 The STPA Process -- 8.3 Identifying Potentially Hazardous Control Actions (Step 1) -- 8.4 Determining How Unsafe Control Actions Could Occur (Step 2) -- 8.5 Human Controllers -- 8.6 Using STPA on Organizational Components of the Safety Control Structure -- 8.7 Reengineering a Sociotechnical System: Pharmaceutical Safety and the Vioxx Tragedy -- 8.8 Comparison of STPA with Traditional Hazard Analysis Techniques -- 8.9 Summary -- Chapter 9. Safety-Guided Design -- 9.1 The Safety-Guided Design Process -- 9.2 An Example of Safety-Guided Design for an Industrial Robot -- 9.3 Designing for Safety -- 9.4 Special Considerations in Designing for Human Controllers -- 9.5 Summary -- Chapter 10. Integrating Safety into System Engineering -- 10.1 The Role of Specifications and the Safety Information System -- 10.2 Intent Specifications -- 10.3 An Integrated System and Safety Engineering Process -- Chapter 11. Analyzing Accidents and Incidents (CAST) -- 11.1 The General Process of Applying STAMP to Accident Analysis -- 11.2 Creating the Proximal Event Chain -- 11.3 Defining the System(s) and Hazards Involved in the Loss -- 11.4 Documenting the Safety Control Structure -- 11.5 Analyzing the Physical Process -- 11.6 Analyzing the Higher Levels of the Safety Control Structure -- 11.7 A Few Words about Hindsight Bias and Examples -- 11.8 Coordination and Communication -- 11.9 Dynamics and Migration to a High-Risk State -- 11.10 Generating Recommendations from the CAST Analysis -- 11.11 Experimental Comparisons of CAST with Traditional Accident Analysis -- 11.12 Summary -- Chapter 12. Controlling Safety during Operations -- 12.1 Operations Based on STAMP -- 12.2 Detecting Development Process Flaws during Operations -- 12.3 Managing or Controlling Change 12.4 Feedback Channels -- 12.5 Using the Feedback -- 12.6 Education and Training -- 12.7 Creating an Operations Safety Management Plan -- 12.8 Applying STAMP to Occupational Safety -- Chapter 13. Managing Safety and the Safety Culture -- 13.1 Why Should Managers Care about and Invest in Safety? -- 13.2 General Requirements for Achieving Safety Goals -- 13.3 Final Thoughts -- Chapter 14. SUBSAFE: An Example of a Successful Safety Program -- 14.1 History -- 14.2 SUBSAFE Goals and Requirements -- 14.3 SUBSAFE Risk Management Fundamentals -- 14.5 Certification -- 14.6 Audit Procedures and Approach -- 14.7 Problem Reporting and Critiques -- 14.8 Challenges -- 14.9 Continual Training and Education -- 14.10 Execution and Compliance over the Life of a Submarine -- 14.11 Lessons to Be Learned from SUBSAFE -- 14.4 Separation of Powers -- Epilogue -- Appendixes -- A. Definitions -- B. The Loss of a Satellite -- B.1 The Physical Process -- B.2 Description of the Proximal Events Leading to the Loss -- B.3 Physical Process and Automated Controller Failures and Dysfunctional Interactions -- B.4 Launch Site Operations -- B.5 Air Force Launch Operations Management -- B.6 Software/System Development of the Centaur Flight Control System -- B.7 Quality Assurance (QA) -- B.8 Developer Testing Process -- B.9 Independent Verification and Validation (IV & -- V) -- B.10 Systems Engineering -- B.11 Prime Contractor Project Management -- B.12 Defense Contract Management Command (DCMC) -- B.13 Air Force Program Office -- C. A Bacterial Contamination of a Public Water Supply -- C.1 Proximate Events at Walkerton -- C.2 System Hazards, System Safety Constraints, and Control Structure -- C.3 Physical Process View of the Accident -- C.4 First-Level Operations -- C.5 Municipal Government -- C.6 Provincial Regulatory Agencies (Ministries) -- C.7 Provincial Government C.8 The Structural Dynamics -- C.9 Addendum to the Walkerton Accident Analysis -- D. A Brief Introduction to System Dynamics Modeling -- References -- Index Intro -- Contents -- Series Foreword -- Preface -- Relationship to Safeware -- Audience -- Contents -- Acknowledgments -- I. Foundations -- Chapter 1. Why Do We Need Something Different? -- Chapter 2. Questioning the Foundations of Traditional Safety Engineering -- 2.1 Confusing Safety with Reliability -- 2.2 Modeling Accident Causation as Event Chains -- 2.3 Limitations of Probabilistic Risk Assessment -- 2.4 The Role of Operators in Accidents -- 2.5 The Role of Software in Accidents -- 2.6 Static versus Dynamic Views of Systems -- 2.7 The Focus on Determining Blame -- 2.8 Goals for a New Accident Model -- Chapter 3. Systems Theory and Its Relationship to Safety -- 3.1 An Introduction to Systems Theory -- 3.2 Emergence and Hierarchy -- 3.3 Communication and Control -- 3.4 Using Systems Theory to Understand Accidents -- 3.5 Systems Engineering and Safety -- 3.6 Building Safety into the System Design -- II. Stamp: An Accident Model Based On Systems Theory -- Chapter 4. A Systems-Theoretic View of Causality -- 4.1 Safety Constraints -- 4.2 The Hierarchical Safety Control Structure -- 4.3 Process Models -- 4.4 STAMP -- 4.5 A General Classification of Accident Causes -- 4.6 Applying the New Model -- Chapter 5. A Friendly Fire Accident -- 5.1 Background -- 5.2 The Hierarchical Safety Control Structure to Prevent Friendly Fire Accidents -- 5.3 The Accident Analysis Using STAMP -- 5.4 Conclusions from the Friendly Fire Example -- III. Using Stamp -- Chapter 6. Engineering and Operating Safer Systems Using STAMP -- 6.1 Why Are Safety Efforts Sometimes Not Cost-Effective? -- 6.2 The Role of System Engineering in Safety -- 6.3 A System Safety Engineering Process -- Chapter 7. Fundamentals -- 7.1 Defining Accidents and Unacceptable Losses -- 7.2 System Hazards -- 7.3 System Safety Requirements and Constraints -- 7.4 The Safety Control Structure |
| Title | Engineering a Safer World |
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