Managing Risk: The Human Element -- Contents -- About the Authors -- Preface -- Acknowledgements -- Definitions of Risk and Risk Management -- Introduction: The Art of Prediction and the Creation of Order -- Risk and Risk Management -- Defining Risk -- Managing Risk: Our Purpose, Plan and Goals -- Recent Tragic Outcomes -- Power Blackouts, Space ShuttleLosses, Concorde Crashes, Chernobyl, Three Mile Island, and More . . . -- How Events and Disasters Evolve in a Phased Development: The Human Element -- Our Values at Risk: The Probable Improvement -- Probably or Improbably Not -- How This Book Is Organised -- References -- Technical Summary -- Defining the Past Probability -- Predicting Future Risk: Sampling from the Jar of Life -- A Possible Future: Defining the Posterior Probability -- The Engineers have an Answer: Reliability -- Drawing from the Jar of Life: The Hazard Function and Species Extinction -- Experiencing Failure: Engineering and Human Risk and Reliability -- Experience Space -- Managing Safely: Creating Order Out of Disorder Using Safety Management Systems -- Describing the Indescribable: Top-Down and Bottom-Up -- What an Observer Will Observe and the Depth of Our Experience -- References -- 1: The Universal Learning Curve -- Predicting Tragedies, Accidents and Failures: Using the Learning Hypothesis -- The Learning Hypothesis: The Marketplace of Life -- Learning in Homo-Technological Systems (HTSs): The Way a Human Learns -- Evidence of Risk Reduction by Learning -- Evidence of Learning from Experience: Case Studies -- Evidence of Learning in Economics -- Evidence of Learning in Engineering and Architecture: The Costs of Mistakes -- Learning in Technology: The Economics of Reducing Costs -- Evidence of Learning Skill and Risk Reduction in the Medical Profession: Practice Makes Almost Perfect.

Learning in HTSs : The Recent Data Still Agree -- The Equations That Describe the Learning Curve -- Zero Defects and Reality -- Predicting Failures: The Human Bathtub -- Experience Space: The Statistics of Managing Safety and of Observing Accidents -- Predicting the Future Based on Past Experience: The Prior Ignorance -- Future Events: The Way Forward Using Learning Probabilities -- The Wisdom of Experience and Inevitability -- The Last, First or Rare Event -- Conclusions and Observations: Predicting Accidents -- References -- 2: The Four Echoes -- Power Blackouts, Space Shuttle Losses, Concorde Crashes, and the Chernobyl and Three Mile Island Accidents -- The Combination of Events -- The Problem Is the Human Element -- The Four Echoes Share the Same Four Phases -- The First Echo: Blackout of the Power Grid -- Management's Role -- The First Echo: Findings -- Error State Elimination -- The Second Echo: Columbia/Challenger -- The Results of the Inquiry: Prior Knowledge -- The Second Echo: The Four Phases -- Management's Responsibility -- Error State Elimination -- The Third Echo: Concorde Tires and SUVs -- Tire Failures: The Prior Knowledge -- The Third Echo: The Four Phases -- Management's Responsibility -- Error State Elimination -- The Fourth Echo: Chernobyl -- An Echo of Three Mile Island -- The Consequences -- Echoes of Three Mile Island -- The Causes -- Error State Elimination -- The Fourth Echo: The Four Phases -- Regulatory Environment and Practices -- Case Study: Regulation in Commercial Aviation -- a) Regulations Development -- b) Compliance Standards -- c) Accident Investigation -- Addressing Human Error -- Management Responsibilities -- Designing to Reduce Risk and the Role of Standards -- Conclusion and Echoes: Predicting the Unpredictable -- References.

3: Predicting Rocket Risks and Refinery Explosions: Near Misses, Shuttle Safety and Anti - Missile Defence Systems Effectiveness -- Learning from Near Misses and Prior Knowledge -- Problems in Quantifying Risk: Predicting the Risk for the Next Shuttle Mission -- Estimating a Possible Range of Likelihoods -- Learning from Experience: Maturity Models for Future Space Mission Risk -- Technology versus Technology -- Missiles Risks over London: The German Doodlebug -- Launching Missile Risk -- The Number of Tests Required -- Estimating the Risk of a Successful Attack and How Many Missiles We Must Fire -- Uncertainty in the Risk of Failing to Intercept -- What Risk Is There of a Missile Getting Through: Missing the Missile -- Predicting the Risk of Industrial Accidents: The Texas City Refinery Explosion -- From Lagging to Leading: Safety Analysis and Safety Culture -- Missing Near Misses -- What These Risk Estimates Tell Us: The Common Sense Echo -- References -- 4: The Probability of Human Error: Learning in Technological Systems -- What We Must Predict -- The Probability Linked to the Rate of Errors -- The Definition of Risk Exposure and the Level of Attainable Perfection -- Comparison to Conventional Social Science and Engineering Failure and Outcome Rate Formulations -- The Learning Probabilities and the PDFs -- The Initial Failure Rate and Its Variation with Experience -- The 'Best' MERE Risk Values -- Maximum and Minimum Likely Outcome Rates -- Standard Engineering Reliability Models Compared to the MERE Result -- Future Event Estimates: The Past Predicts the Future -- Statistical Bayesian-Type Estimates: The Impact of Learning -- Maximum and Minimum Likelihood -- Comparison to Data: The Probability of Failure and Human Error -- Comparison of the MERE Result to Human Reliability Analysis -- Implications for Generalised Risk Prediction.

Conclusions: The Probable Human Risk -- References -- 5: Eliminating Mistakes: The Concept of Error States -- A General Accident Theory: Error States and Safety Management -- The Physics of Errors -- The Learning Hypothesis and the General Accident Theory -- Observing Outcomes -- A Homage to Boltzmann: Information from the Grave -- The Concept of Depth of Experience and the Theory of Error States -- The Fundamental Postulates of Error State Theory -- The Information in Error States: Establishing the Risk Distribution -- The Exponential Distribution of Outcomes, Risk and Error States -- The Total Number of Outcomes -- The Observed Rate and the Minimum Number of Outcomes -- Accumulated Experience Measures and Learning Rates -- The Average Rate -- Analogy and Predictions: Statistical Error Theory and Learning Model Equivalence -- The Influence of Safety Management and Regulations: Imposing Order on Disorder -- The Risk of Losing a Ship -- Distribution Functions -- The Most Probable and Minimum Error Rate -- Learning Rates and Experience Intervals: The Universal Learning Curve -- Reducing the Risk of a Fatal Aircraft Accident: The Influence of Skill and Experience -- Conclusions: A New Approach -- References -- 6: Risk Assessment: Dynamic Events and Financial Risks -- Future Loss Rate Prediction: Ships and Tsunamis -- Predicted Insurance Rates for Shipping Losses: Historical Losses -- The Premium Equations -- Financial Risk: Dynamic Loss and Premium Investments -- Numerical Example -- Overall Estimates of Shipping Loss Fraction and Insurance Inspections -- The Loss Ratio: Deriving the Industrial Damage Curves -- Making Investment Decisions: Information Drawing from the Jar of Life -- Information Entropy and Minimum Risk -- Progress and Learning in Manufacturing.

Innovation in Technology for the Least Product Price and Cost: Reductions During Technological Learning -- Cost Reduction in Manufacturing and Production: Empirical Elasticity 'Power Laws' and Learning Rates -- A New General Formulation for Unit Cost Reduction in Competitive Markets: The Minimum Cost According to a Black-Scholes Formulation -- Universal Learning Curve: Comparison to the Usual Economic Power Laws -- The Learning Rate b-Value 'Elasticity' Exponent Evaluated -- Equivalent Average Total Cost b-Value Elasticity -- Profit Optimisation to Exceed Development Cost -- The Data Validate the Learning Theory -- a) Aircraft Manufacturing Costs Estimate Case -- b) Photovoltaic Case -- c) Air Conditioners Case -- d) Ethanol Prices Case -- e) Windpower Case -- f) Gas Turbine Power Case -- g) The Progress Curve for Manufacturing -- Non-Dimensional UPC and Market Share -- Conclusions: Learning to Improve and Turning Risks into Profits -- References -- 7: Safety and Risk Management Systems: The Fifth Echoes -- Safety Management Systems: Creating Order Out of Disorder -- Workplace Safety: The Four Rights, Four Wrongs and Four Musts -- Acceptable Risk: Designing for Failure and Managing for Success -- Managing and Risk Matrices -- Organisational Factors and Learning -- A Practical 'Safety Culture' Example: The Fifth Echo -- Safety Culture and Safety Surveys: The Learning Paradox -- Never Happening Again: Perfect Learning -- Half a World Apart: Copying the Same Factors -- Using a Bucket: Errors in Mixing at the JCO Plant -- Using a Bucket: Errors in Mixing at the Kean Canyon Explosives Plant -- The Prediction and Management of Major Hazards: Learning from SMS Failures -- Learning Environments and Safety Cultures: The Desiderata of Desires -- Safety Performance Measures: Indicators and Balanced Scorecards.

Safety and Performance Indicators: Measuring the Good.