IV. COORDINABILITY AND CONSISTENCY IN SOCIOTECHNICAL SYSTEMS
The concept of coordinability and consistency will now be introduced and an attempt will be made to show how the same is related to accident causation. In other words, the principle of coordinability and consistency will be used to find the point of failure in the sociotechnical system which resulted in an accident.
It may be argued that such an approach for accident causation is relatively old, however the attempt being made in this paper is to show that coordinability and consistency can be applied to modern systems as well, showing that it is still an important concept till date for system safety.
All sociotechnical systems are multilevel systems. The design and analysis of such systems is usually broken down into subsystems in a in a hierarchical structure. [4] A diagram of a standard two-level hierarchical system is shown in Fig 4, where, as expected, two levels can be found, namely the lower level and the upper level. The lower level consists of the process level, where the process level has been divided into N sub-systems. The sub-systems are connected to each other because there is either material or information flows between these sub-systems. Each sub-system has its own decision unit, which tries to control the behavior of the sub-system so that the objectives of this particular sub-system would be met. The decision unit can also use feedback information from the sub-system to improve its’ control policy’. However, quite often the objectives of the sub-systems are conflicting, resulting in a poor overall performance.
[5]A system in this context is defined as a function S: UY between a set of inputs U and a set of out-puts Y. In particular, a decision-...
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...n thus be seen that lack of consistency was used to identify accident causation.
VI CONCLUSION
Any given sociotechnical system can be operated and used safely if and only if coordinability and consistency are ensured from each level of the hierarchy to the next. It has also been shown that the lack of any one of these two terms will result in an accident, and it can successfully be said that coordinability and consistency can be used for identifying accident causation from where further investigations can take place.
It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system.
As systems become more and more sociotechnical, more complex and more hybrid ensuring that the concept introduced above holds true will assist us in developing more safe systems.
In this essay, the author
Explains that often the objectives of the sub-systems are conflicting, resulting in poor overall performance.
Explains how to check and see if a new flight level is possible and convey the same to the flight crew.
Explains that both the supremal and infimal unit have their own decision problems, and each problem has a solution. coordinability of the system is dependent on answering the question, "is the solution executable?"
Explains that the multilevel hierarchal system is consistent if the overall decision problem is solved when the upper and lower level decision units solve their own decision problems.
Explains that if the supremal and infimal units solve their respective decission problems, implies that coordinability exits.
Explains the concept of coordinability and consistency, but how can these concepts be applied for system safety and accident causation.
Explains that the tenerife airport disaster is considered the worst aviation disaster in the last century, resulting in an estimated 583 fatalities.
Explains the purpose of this analysis is to show the lack of coordinability as the main cause for the accident.
Concludes that if coordinability had been accomplished the accident would have been avoided.
Analyzes the piper alpha disaster as an illustration of the lack of consistency in accident causation.
Explains that gas was handled on the piper alpha platform and compressed prior to its export to shore. heavier components were removed from the gas, collected, and then pumped back into the main oil line via an injection pump.
Explains that the day crew did not complete the work on the psv, which was temporarily replaced with a blind flange until maintenance resumed. the night shift crew and the offshore installation manager were not informed of this situation.
Explains the purpose of this analysis is to show the lack of coordinability as the main cause for the accident.
Explains that the concept of coordinability and consistency is used to find the point of failure in the sociotechnical system which resulted in an accident.
Explains that the system s is said to solve an optimization problem if the decision corresponding to an input u € u, minimizes a given objective function that depends, in general, on both x and
Explains that an upper-level decision-making unit called the coordinator coordinates the decision making of each sub-system via feedback to improve the performance of the system.
Explains that coordinability is of central importance for multilevel systems. it means that there is at least one solution to the supremal decision problem.
Describes the fatal collision between two boeing 747s on the runway of los rodeos airport on march 27, 1977.
Concludes that lack of coordinability can be viewed as one of the main causes of accident causation.
Describes how the crash occurred between bashkirian airlines flight 2937 and dhl flight 611 over überlingen and owingen in southern germany.
Analyzes how the supremal unit provided a solution for the decision problem which was properly executed by the infimal unit. however, the lack of consistency was not communicated to the oim or the night shift crew.
Explains that sociotechnical systems can be operated and used safely if coordinability and consistency are ensured from each level of the hierarchy to the next.
1. Identify the system's constraints. Of necessity this included prioritization so that just the ones that really limit system progress toward the goal.
In this essay, the author
Explains that goldratt's "the goal" is a book about the theory of constraints, which deals with manufacturing constraints and the variability that creates them.
Analyzes how toc states that any system has at least one constraint; otherwise, it would be generating an infinite amount of output.
Recommends identifying the system's constraints and prioritizing the ones that really limit system progress toward the goal.
Explains that once we have decided how to manage the constraints within the system, how about the majority of the resources that are not constraints?
Explains that constraints are not acts of god, but can be reduced or eliminated.
Opines that if we continue to work toward breaking a constraint, it will no longer be one.
Explains that if a constraint is broken, return to step 1. when that happens, there will be another one that is limiting progress to the goal.
Analyzes how eli goldratt uses "the goal" to explain how simple improvement can be. socrates is famous for his method of asking questions in particularly effective ways.
Analyzes how alex and his team use benchmarking and the theory of constraints to transform their mediocre plant into a money-making machine.
Argues that the central premise of the goal can best be summarized as change. it is easy to get a message of ‘focus on what’s important’ from the book.
Explains how the theory of constraints (toc) and the five focusing steps facilitated rogo's being able to implement change.
Explains that goldratt knew that developing the ability to design and implement change was just as important. his appendix "my saga" at the end of the book clearly addresses the need to create, implement, and the disastrous effects of improperly implemented change.
Describes how they work at lucent technologies fiber optic cable plant in norcross, where they manufacture fiber used for phone lines, cable lines and other uses.
Opines that spools with 5k or less of fiber on them should be automatically scrapped. they cite a case study used at the toc world 2000 seminar in st. paul mn.
One of the biggest contributors to the accident was due to operator errors. The operators
In this essay, the author
Explains that an accident happened at the three mile island nuclear power plant in middletown, pennsylvania. the accident caused the core of the reactor to meltdown and release radioactive gas.
Explains that the plant's operators were poorly trained to deal with "less important" accidents due to an oversight by scientists and engineers in charge of the regulations and safety.
Many references to human error are associated with high-profile catastrophes. The publics concern over these high-profile catastrophes puts human error in the spotlight. Some examples of human error catastrophes include: the Tenerife runway collision in 1977, Three Mile Island in 1979, the Bhopal methyl isocyanate tragedy in 1984, the Challenger and Chernobyl disasters of 1986, and the Piper Alpha oil platform explosion in 1988. While these catastrophes put human error concerns in the spotlight, the human error impact on manufacturing operations can be just as detrimental.
In this essay, the author
Explains that human error is a human behavior or conduct that is undesirable, unacceptable, careless, inattentive, reckless, harmful, extreme in variability, or an inappropriate form of risk taking behavior.
Explains that shift work is essential in an industrially developed country. while a majority of research shows that night shift accidents are higher than normal shift operations, there are studies that suggest otherwise.
Compares the work environment and conditions of shift workers and non-shift workers in a study conducted in 1990.
Explains how wong, mcleod, and demers conducted a study to examine the risk of work injury across shift work types in canada.
This theory is the most complex of the three, but is also fairly simple. The Social- Technical theory tries to describe the accident by using all variables as possible cause of failure. This theory looks into the design of the product, how the product I intended to be used and how the workers are trained to use it, but also the actual implementation of the product. Also this type of accident theory looks into the social aspect of the work environment. Looking into the employees ' motivation such as, whether the workers are overworked and tired if they 're busy with other tasks and are unable to focus solely on the task at hand, also a possibility is if the worker has distractions outside of work at home, and finally it could also look into if the worker actually is properly trained and is proficient and knowledgeable about what they are doing. Along with analyzing all the other aspects Social- Technical also looks at the design process the methods used to produce the product, the materials used in the process, and finally the regulations behind the production of the
In this essay, the author
Explains that the chernobyl nuclear accident had many repercussions and caused many to doubt nuclear power across the world.
Explains that the soviet union was on the verge of collapsing. high officials were not willing to share information with many workers of their companies.
Explains that an hro stands for high reliability organization. they believe that failure will not happen in the right environment and situation.
Opines that most nuclear power plants are considered to be hro because of their relatively dangerous nature and if there is a problem it tends to not be small one. the reactor in chernobyl was not an 'hro' because at the time the soviet government did not properly train their employees.
Explains the second kind of accident theory called the natural accident theory (nat). the nat believes that there is no way to avoid accidents and the accidents are evident.
Explains that the nat applies very closely to the chernobyl accident, stating that there is no question whether or not there will be an accident.
Explains the social-technical theory, which tries to describe the accident by using all variables as possible cause of failure.
Explains that many workers at chernobyl were overworked and forced to work hours away from their families. there was also a lack of safety culture in the soviet union.
Explains that the chernobyl reactor blew up due to a lack of specialization and safety protocol. the soviet union collapsed after the disaster.
On its surface, “fault” is defined as the person who caused the vehicle accident. The rules can get a bit complicated based on the amount of damage caused and other factors.
In this essay, the author
Explains that farmers insurance – steve montour in rosemount, mn has the answers to determine who’s liable depending on who has no-fault coverage versus at fault coverage.
Explains that with no-fault coverage, the insurance companies would pick up the tab for each of their respective policyholders.
States that while pip is required in most states, it is generally not a substitute for traditional liability insurance. drivers are also required to have at least the minimum amount of coverage set by that particular state.
Explains that the definition of "fault" is complicated based on the amount of damage caused and other factors. farmers insurance – steve montour is your trusted auto insurance expert to help you decipher what type of coverage offers the most protection.
The first thing to remember is that every accident requires a delicate handling of the laws. Added complexity arises owing to the state jurisdictions and applicable bye-laws.
In this essay, the author
Explains the physical pain, damage to the vehicle, and mental agony associated with an accident on the road.
Advises that every accident requires delicate handling of the laws, owing to state jurisdictions and applicable bye-laws, and in the case of a tractor trailer.
Opines that an attorney experienced in these matters may be able to crack an out-of-court deal, saving you a lot of trouble and mental hassle.
Explains that an attorney must have ample experience in representing clients in tractor trailer accident cases and have a high percentage of wins.
That the accident is such as in the ordinary course of things does not happen if those have the duty, use proper
In this essay, the author
Explains that peter has to justify to the tax office on the status of employment of maria to avoid hefty penalties which might be incurred for failure to do so.
Explains the amount of supervision and how much the company controls, when, how and where maria works. it was agreed between them that peter would only call her in if he was under-staffed or one of his employees had called in sick.
Explains that a court of law can determine breach of duty of care by determining if the breach occurred.
Explains that peter has to show the court of law that the motorist was speeding, stating that he was in control of the vehicle. this confirms that indeed a breach of duty of care had actually taken place.
Describes hussain ashiq's book on general principles of commercial law.
Explains the purpose of an exemption clause to limit or extinguish the liability of one of the parties to which he would otherwise be liable in law.
Explains that c hired a deck chair from the defendant, paid for pence, and obtained an exemption clause on the back of the ticket, which he put into his pocket without reading what was on it.
Analyzes how maria rejects work without any future detriment. peter reluctantly accepts if maria was unavailable when called into work, and her brother al would stand in for her.
Analyzes the risks and rights enjoyed by a self-employed citizen. maria is not in business of her own volition as she can be called into work anytime without expectation of being unavailable.
Explains that peter bears the burden of proving negligence to the court that the speeding motorist committed reasonable evidence of negligence against him. the plaintiff could apply the rule of ‘res ipsa loguitur’ to prove that indeed a breach of duty of care had been committed.
Analyzes how the defendant, the motorist, did not use reasonable care when he exceeded the speed limit thereby causing injuries to the plaintiff and in this case peter.
On the other hand, proximate cause is defined as the ‘dominant cause’ of the incurred loss. It can also be defined as the cause that has the most significant impact, which brings about the loss under a first party policy when two or perils that are more independent operate concurrently to result in a loss. However, courts employ a set of proximate cause rules in order to determine causation disputes especially when a policy states that it covers or excludes those losses “caused by” an insured peril, and there is more than one peril at play. The significance of the proximity cause is to determine whether the policy should cover the loss as resulted from the insured peril. From this information, it is safe to state that the insured is often the beneficiary of such a suit. This is because it is sometimes hard to prove that the peril was not the dominant factor that caused the loss. For instance in the case of Kastor Navigation Co Ltd & Another Vs Axa Global Risks (U.K) Ltd & others, it was hard for them to prove that the fire was not the dominant peril that caused the sinking of the s...
In this essay, the author
Explains that proximate cause is defined as the ‘dominant cause’ of the incurred loss and the cause that has the most significant impact.
Explains gim1050 - legal basis of insurance: insurable interest.
Narrates the case of kastor v. agf, retrieved from http://haberciniz.biz.
Explains marine insurance is mandated with covering the loss or damage of ships, terminals, cargo, as well as other transport or cargo by which there is transference of property acquired or held between both points of destination and origin.
Explains that a fire broke out in the kastor too's engine room and sank 15hrs later. the judge awarded the owners £3.49 million inclusive of interest.
Cites the university of nottingham's law of marine insurance (2000, june 17).
Cites the document kastor navigation co. ltd. v. agf mat.
...a system is critical. This is because this system is so elaborate, expensive, and has to be considered right at the inception of the design process. The associated benefits can be identified and evaluated based on the following:
In this essay, the author
Explains that as bipv systems are poly-fucntional building materials, they are designed to serve more than one function.
Describes thin crystal products such as solar cells made from crystalline silicon as single or poly-crystalline wafers.
Describes thin-film products, which include very thin layers of photovoltaicly active material placed on a glass superstrate.
Explains that pv modules are the most integral of the pv system. they might be thin-film, crystalline, transparent, semi-transparent, or opaque.
Explains that batteries interface with electrical charge and energy and require a charge controller to regulate the power into and out of the battery storage bank.
Explains that the power generated needs a power storage system, generally comprised of the utility grid in utility-interactive systems or, batteries in stand-alone systems.
Explains that a bipv/pv system requires power conversion equipment to convert the pv modules dc output to ac compatible with the grid.
Explains that the whole system needs a sound and efficient wiring connection to generate electrical power. the system's performance is further compounded by the fact that it needs to operate in an environment often exposed to the weather elemtns.
Opines that the whole system needs an apt structural system to support this complex system and allow it to render all its functions.
Explains the versatility of the bipv system and the fact that it can be used as the building skin itself allows it to manifest itself many different elements and systems.
Illustrates the versatility and spectrum of bipv’s application in the building system in two steps.
Explains that bipv products are categorized in several different ways, based on the product descriptions from the manufacturers.
Explains that lightweight and flexible roofs are beneficial for ease of installation and keeping within the prevailing weight constraints. flexibility allows providing or adapting to varying inclinations.
Explains that bipv tile products can cover the entire roof or selected parts of the roof. they are arranged in modules keeping the appearance of traditional roof tiles.
Explains that the bipv modules are similar to conventional pv modules, but they differ in the fact that they are made with weather skin solutions.
Explains how the bipv system is designed to become the outer skin and weather barrier of the building envelope.
Explains that bipv is a glass element that provides degrees of shading to provide both indoor thermal comfort as well as daylighting.
Explains that pv materials can be designed to be fitted onto a facade to serve as awnings and be part of an aesthetic scheme.
Explains that the majority of the application is for the continuos façade or window systems, while shading systems find lesser preference.
Explains that the bipv product is nailed to the roof deck, almost the same way that traditional asphalt shingles are attached to a roof.
Explains the different ways of installing a pv system, such as mounting onto steel plates and installation on the roof substrate.
Explains that semi-transparent pv glazing can improve performance of the pv system, since they are more effective than transparent ones. open-air pv atriums are economical.
Explains that pv shade screens are effective since they are more often than not horizontal and provide a large area for generating electricity. they are less expensive than other bipv systems because extra ventilation of the pv modules is not needed.
Describes the large-area pv module with a dedicated, integrally mounted, unitized curtain walling system. the large spaces between the pv cells can be utilized to allow direct natural light to transmit through the module.
Explains that sunshades offer a versatile and flexible surface for designers to integrate photovoltaics into new as well as existing buildings.
Describes the large-area pv module with a dedicated, integrally mounted, unitized curtain walling system. the large spaces between the pv cells can be utilized to allow direct natural light to transmit through the module.
Explains that pv-powered smart windows induce intelligence, based on the insolation of sunlight and solar heat, and can dynamically switch between darkened and clear states.
Describes a hybrid flat-plate photovoltaic/thermal (pv/t) collector to achieve both electricity and thermal energy.
Explains that the value of the bipv systems can directly affect the decision making process. assessing or laying a prognosis to identify the benefits is critical.
Explains that the integrated building energy system will have to be procured through the construction budget. the bipv system offsets the buildings operational energy demand and creates savings that reduce operating budgets.
Explains that the demand for renewable and non-polluting sources of energy is increasing rapidly. building integrated photo-voltaics (bipv) is a novel and versatile tool for catering to the energy demands of the built space.
Explains that bipvs are integrated into the building envelope and require a holistic design that reduces energy demand, generates electricity on site, and functions as the weathering skin.
Explains how integrated energy conservation, energy efficiency, building envelope design, and pv technology maximizes energy savings and makes the most of opportunities to use bipv systems.
Explains that the functioning of a pv/bipv system can be laid out as flow-charts. the standard element or basic element is the pv module.
Explains that solar cells are interconnected, encapsulated, laminated primarily in glass, and framed to form a module. sunlight induces photovoltaic effect generating power in the form of unregulated dc electric power.
Explains that bipvs can provide a variety of options for windows, glassed or tiled facades and roofs. solar cell glazing modules transmit daylight and serve as protection from the weathering elements of rain and sun.
Opines that pv facades need to generate energy and provide a sound building envelope with utmost integrity to protect against weather elements, as well as shading schemes to provide multiple benefits.
Explains that laminated glass comprises two pieces of glass and solar pv cells sandwiched between them; an encapsulant material, and a translucent or colored backsheet. bipv panels can be used as spandrel panels, patterned or fritted glass.
Explains that bipv roofing systems need to perform the conventional functions of a roof and at the same time be able to generate electricity.
Describes the bipv metal roofing panels, which are laid side by side next to each other and a cap is placed over the edges. pv laminates are attached to polystyrene insulation, providing thermal insulation rated r-10 or r-15.
Explains that photovoltaic systems can be of great benefit in the upcoming future with the advent of pre-fab for almost everything.
...judgments (though not necessarily in the context of causation) placed greater emphasis on two themes. The first is the notion of personal responsibility. The other is the desirability for negligence law to cohere with other areas of law. Injecting these principles into causation would make this element more comprehensible and predictable. More specifically, it would limit the scope of liability in negligence”.
In this essay, the author
Opines that the ipp report provides people with a better understanding of the act, but some of its recommendations frustrate what has been said in case law.
Opines that the ipp report suggests a common sense approach to statutory interpretation, which will broaden the scope of liability and leave no room for tests that determine if the damage was too remote.
Opines that the ipp reports approach was to create recommendations that could be used in the act, but due to the small time frame, the recommendations were not taken into account.
Explains that causation is one of the most esoteric and poorly defined legal principles; it leads to a large degree of uncertainty.