Читать книгу Root Cause Failure Analysis - Trinath Sahoo - Страница 29

The human roots are those human errors that result in the mechanisms that caused the physical failures. What is the error committed that lead to the physical cause?

Someone did the wrong thing knowingly or unknowingly. We asked what caused the person to commit this mistake. A good example is, the TITANIC was sailing full speed ahead despite concerns about icebergs was Smith’s biggest misstep. the TITANIC was actually speeding up when it struck the iceberg as it was White Star chairman and managing director, Bruce Ismay’s, intention to run the rest of the route to New York at full speed, arrive early, and prove the TITANIC’s superior performance. Ismay survived the disaster and testified at the inquiries that this speed increase was approved by Captain Smith and the helmsman was operating under his Captain’s direction.