Not sure why you got so heavily downvoted. It's a reasonable question. There are a few books looking at causes of human errors that result in death or accident.
Usually the cause is wider than just "Bob didn't follow procedure", and includes things like "Management had Bob working 56 hour weeks in scattered locations which caused fatigue".
People incentivise the wrong thing; they misunderstand the psychology of work[1]; they use poor design; etc.
Other examples include surgeon's resistance to counting equipment before and after surgery - this WHO protocol saves lives and reduces adverse events but some surgeons strongly resisted implementing it.
> BRITISH NUCLEAR Fuels has admitted that it has discovered twice as many faked safety checks on its highly dangerous mixed-oxide fuel as previously thought.
> The nuclear fuel was destined to be part of a second export consignment to Japan, where environmentalists are planning huge protests against the scheduled arrival of the first consignment later today.
> The company originally estimated that quality-control data relating to 11 lots of mixed-oxide (MOX) fuel had been falsified, but an internal investigation has identified 22 lots that were forged. British Nuclear Fuels (BNFL) launched its inquiry last week after The Independent revealed serious lapses in its quality-control procedures relating to MOX fuel for Japan. Three employees have been suspended.
Usually the cause is wider than just "Bob didn't follow procedure", and includes things like "Management had Bob working 56 hour weeks in scattered locations which caused fatigue".
People incentivise the wrong thing; they misunderstand the psychology of work[1]; they use poor design; etc.
Other examples include surgeon's resistance to counting equipment before and after surgery - this WHO protocol saves lives and reduces adverse events but some surgeons strongly resisted implementing it.
And then you have outright forging of paperwork. from 1999 - http://www.state.nv.us/nucwaste/news/nn10199.htm
> BRITISH NUCLEAR Fuels has admitted that it has discovered twice as many faked safety checks on its highly dangerous mixed-oxide fuel as previously thought.
> The nuclear fuel was destined to be part of a second export consignment to Japan, where environmentalists are planning huge protests against the scheduled arrival of the first consignment later today.
> The company originally estimated that quality-control data relating to 11 lots of mixed-oxide (MOX) fuel had been falsified, but an internal investigation has identified 22 lots that were forged. British Nuclear Fuels (BNFL) launched its inquiry last week after The Independent revealed serious lapses in its quality-control procedures relating to MOX fuel for Japan. Three employees have been suspended.