Rank: Super forum user 
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I'm looking for some case studies where someone has been faced with a situation outside the routine (where something has gone wrong) and has to stop and think what best to do, instead of carrying on with their normal routine. The sort of thing exemplified by the "rule-based mistake" quoted in HSG48 where someone ignored a high level alarm (because he didn't believe it could be right) and overfilled a tank.
Can anyone point me to a source of similar examples?
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Rank: Forum user 
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Kate if my memory serves me correctly I think the 'Kegworth Air Accidnet' would come under the rule based error category.
In this case the pilot applied a set of rules which should have helped but due to other factors the procedure was not completed and in fact he shut doen the wrong engine.
From memery but sure if you Google 'Kegworth Air Disaster' you will find further info. Herald of Free Enterprise may be another worth looking at.
regards
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Rank: Super forum user
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Kate,
I'd take a look at the Kegworth Air Disaster. It's a bit of a grey area as to whether it's rule or skill based but some good learning in there
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Rank: Super forum user
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'3 mile island' is a case to look at
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Rank: Super forum user
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Thanks all - just the sort of thing I was looking for.
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Rank: Forum user
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Kate, having operated nuclear power plant and other engineering systems, there should be SOP Standard operating Procedures for normal operations and also Emergency Operating Procedures for those outside the norm. Unfortunately neither accounts for the numpty factor when persons ignore the system alarms.Chernobyl is a classic example were the engineers pushed things too far.
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Rank: Forum user
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It may be what you are looking at is now called Non-Technical Skills. A good book on it is "Safety at the sharp End" The second chapter deals with Situation Awareness with some good examples. Its a good study of actions outside the routine.
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Rank: Super forum user 
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Kate
A more recent example is the DeepWater Horizon disaster...you could make a career out of the errors with that one!
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Rank: Super forum user
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Well, as I already have Texas City in my presentation I don't want to look as if I have it in for BP ...
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Rank: Forum user
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Hi Kate
I have something on the Kegworth air crash you might find useful
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