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Courtesy of CRC Press/Taylor & Francis Group
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Hazardous process
Safety constraints
Hierarchical control system
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Accident
Accident trajector
y
Fallible board decisions
and policy
Line management problems
Local failures
Inadequate defences
Unsafe acts
015x002.eps
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Mind
World
015x003.eps
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015x004.tif
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Did an error or
violation occur?
Was there a
system
failure?
No
Yes
Yes No
Review
procurement and
maintenance
procedures
Unforeseeable
occurrence
True accident
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Consider whether the following human factors were
present
Q1: Error/violation occurred
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Q3: Wider
underlying causes?
Q2: Human
Factors present
Missing
requirements at
initial procurement
stage
Poor planning and
assessment of
cumulative risk
Extreme heat (ENV)
Equipment not
fit for purpose
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Withdrawal times
73
57
Means
Max dev
Min dev
80(b)
(a)
Dialogue I (ATM A)
2. ID user
2.1 Enter
PIN 3.1 Fast cash
2. ID user
3. Show
main
menu
4.
Amount
chosen
5.
Confirm
amount
6.
Accounts
displayed
8. Card
dispensed
10. End
transaction
Dialogue II (ATM B, C, D)
4.1 Display
other
accounts
5.1 Display
5 fixed
amount
4. Choose
account
(Accounts
displayed)
5. Choose
amount
6. Dispense
cash and slip
if user
requests slip
3. Show
main
menu
7. Show
main
menu
3. Main
menu
8. End
transaction
8.1
Dispense
card
70
60
FIGURE 15.8 ATM dialogs. In A, dialog I, the transaction ends with the card being returned after the cash
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