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The importance of disaster investigations For Systems Engineers.

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The importance of disaster investigations For Systems Engineers - What is a Systems Engineer? In the modern industry engineering systems are becoming more complex by the day. Therefore a need for elite engineers i.e. the Systems Engineer, capable of applying a wide range of engineering disciplines to a variety of tasks from product design and development from requirements analysis to simulation to manufacturing and marketing etc... is essential. Such engineers work within a team at the heart of the organisation where the design and development of a project is carried out. At this stage it is of great importance that every aspect of the design is studied accurately in order to ensure the final product works effectively, efficiently and safely. However, although maximum effort is made during the design, it is impossible to produce a result 100% efficient. This unfortunately leads to the occurrence of accidents and in some extreme cases to a disaster. By carrying out investigations into the disasters and their causation, lessons can be learnt and employed in future designs. This allows the team of engineers to improve the performance and efficiency of the system whilst maintaining the maximum safety levels. - Disasters and why they happened? > Air disasters caused due to faulty design: There have been historically countless cases of confusion in handling the flaps and the gear controls on the DC3 aircraft as they are in close proximity to each other and of similar shape. ...read more.


The cause of this disaster proved to be a combination of human error and faulty design. Primarily due to the poor and inefficient ground control and crowd management system, and secondly the existence of ground design faults which prevented the crowds from exiting the stands in the event of an emergency. As a result football stadiums are now designed without fences around the pitch and standing terraces have been abolished. How do Systems Engineers learn from disasters? We are now going to take a look at a disaster that has occurred in the past and see how this relates to the design cycle (Fig.1.1). By doing this, the importance of feedback from disaster investigations for systems engineers and how the information is incorporated will be illustrated. We will use the Chernobyl disaster as an example to relate to the diagram. April 26, 1986 saw the world's worst known nuclear reactor disaster to date. The problem arose from an improperly supervised experiment conducted at a nuclear plant in a Ukrainian town, Chernobyl, located approximately 130 km north of Kiev. The experiment was undertaken with the water-cooling system turned off which led to an uncontrolled reaction, that in turn caused a steam explosion. The reactor's protective covering was blown off, and approximately 100 million curies of radionuclides were released into the atmosphere. ...read more.


Ignorance and human errors are aspects of life which may be controlled but never eliminated. Designing to prevent: To prevent disasters from happening there are a wide range of factors to take in to consideration as we have seen. The information from investigations has proved to be a crucial asset to the systems engineer whose responsibility is on going as these systems become more complex. Unfortunately the best why we can prevent an incident occurring is by learning from someone else's mistake. Below is a short list of lessons learnt that hopefully will help engineers in the future during the designs process: - Primarily design for the environment and the operator, and secondly for the task. - Reduce the amount of stress inflicted on the individual as it has been shown that where high levels of stress exist, errors are more likely to occur. - Design against human short cuts that could possibly have disastrous effects. - Use feedback from previous events to modify future designs. - Ensure operating procedures and instructions exist and are understandable. - Staff must be trained in every aspect of their operating condition and in the event of an emergency should have a good understanding of safety procedures. - Ensure maintenance can be effectively carried out. - The conditions of the working environment will have a serious effect, for example a pilots performance will be effected if say the cockpit has improper lighting or if the control panels vibrate due to the aircraft's propulsion. ...read more.

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