Many serious large-scale technological systems' accidents, having grave conse quences, such as those of Three Mile Island, Bhopal and Chernobyl, have pri marily been attributed to "operator error." However, further investigation has revealed that a large majority of these incidents are caused by a combination of many factors whose roots can be found in the lack of human factors (micro- and macro-ergonomics) considerations. Relevant human factor considera tions, the causes of human error, and commonalities of human factor problems in major disasters are briefly reviewed. We concluded that system accidents are caused by the way the (system) parts — engineered and human — fit together and interact. Also, on many occasions, the error and the resultant failures are both the attribute and effect of such factors as complicated operational pro cesses, ineffective training, non-responsive managerial systems, non-adaptive organizational designs, haphazard response systems, and sudden environmen tal disturbances, rather than being their cause. Recommendations for preven tion of such accidents are provided.
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References
1.
Agarwal, A., Merrifield, J. and Tandon, R., 1985. No Place to Run: Local Realities and Global Issues of the Bhopal Disaster. Highlander Research and Education Center, New Market, TN.
2.
Bailey, R.W., 1989. Human Performance Engineering: Using Human Factors/Ergonomics to Achieve Computer System Usability (2nd ed.). Prentice-Hall, Englewood Cliffs, NJ .
3.
Baldissera, A., 1988. Incidenti anormali: una critica della teoria degli incidenti tecnologici ci C. Perrow (Abnormal incident: a critique of G. Perrow's theory of technological incidents), Reference Paper presented at the International Conference on Joint Design of Technology, Organization and People Growth, Venice, Scuola Grande di San Rocco, Oct. 12-14.
4.
Baum, A., 1988. Disasters, natural and otherwise. Psychology Today, April: 57-60.
5.
Baum, A., Gatchel, R. and Schaeffer, M., 1983. Emotional, behavioral and physiological effects of chronic stress at Three Mile Island. Journal of Consulting and Clinical Psychology, 51: 656-672.
6.
Bennett, L.L., 1987. Nuclear power programmes in developing countries: promotion and financing. IAEABulletin, 29(4): 37-40.
7.
Bordewich, F., 1987. The lessons of Bhopal. The Atlantic, March: 30-33.
The Chernobyl Accident and its Consequences, 1988. United Kingdom Atomic Energy Authority, London.
10.
Cherns, A.B., 1962. In: A.T. Welford (Editor), Society: Problems and Methods of Study. Routledge and Kegan Paul, London.
11.
Comptroller General Report on the Congress of the United States, 1980. Three Mile Island: the Most Studied Nuclear Accident in History. The United States General Accounting Office, Washington, DC.
12.
Csik, B.J. and Schenk, K., 1987. Nuclear power in developing countries: requirements and constraints. IAEABulletin, 29(2): 39-42.
13.
Davidson, L. and Baum, A., 1986. Chronic stress and posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 54: 303-308.
14.
Everest, L., 1985. Beyond the Poison Cloud: Union Carbide's Bhopal Massacre . Banner Press, Chicago, IL.
15.
Feynman, R.P., 1986. Personal observations on reliability of Shuttle. In: Report of the Presidential Commission on the Space Shuttle Challenger Accident, Vol. II. U.S. Government Printing Office, Washington, DC.
16.
Gale, R.P. and Hauser, T., 1988. Final Warning: The Legacy of Chernobyl. Warner Books, New York.
17.
Goldman, M.L., 1986. Keeping the cold war out of Chernobyl. Technology Review, July: 18-19.
18.
International Confederation of Free Trade Unions (ICFTU), 1985. The Trade Union Report on Bhopal. ICFTU, Brussels.
19.
Jenkins, R., 1990. Bhopal: Five years later. InThese Times , July: 12-13.
20.
Kemeny, J., 1980. Saving the American democracy: the lessons of Three Mile Island. Technology Review, 83(7): 65-75.
21.
Kleindorfer, P.R. and Kunreuther, H.C. (Editors), 1987. Insuring and Managing Industrial Risks: From Seveso to Bhopal and Beyond. Springer , New York.
22.
Krishnan, U., 1987. Ergonomics/human factors: engineering applications — a review. Paper presented at a lecture session at the Center for Ergonomics of Developing Countries (CEDC)LuleaUniversity of Technology, Sweden (citation is by the author's permission).
23.
MacKenzie, D., 1985. Design failings that caused Bhopal disaster. New Scientist, March: 3-4.
24.
Meshkati, N., 1988. An integrative model for designing reliable technological organizations: the role of cultural variables. Invited position paper for the World Bank Workshop on Safety Control and Risk Management in Large-Scale Technological Operations, World Bank, Washington, DC, Oct. 18-20.
25.
Meshkati, N., 1989a. An etiological investigation of micro- and macroergonomic factors in the Bhopal disaster: lessons for industries of both industrialized and developing countries. International Journal of Industrial Ergonomics, 4: 161-175.
26.
Meshkati, N., 1989b. Critical issues in the safe transfer of large-scale technological systems to the Third World: an analysis and agenda for research. Invited position paper for the World Bank Workshop in Risk Management (in Large-Scale Technological Operations), Organized by the World Bank and the Swedish Rescue Service Board, Karlstad, Sweden, Nov. 6-11.
27.
Meshkati, N., 1989c. Technology transfer to developing countries: a tripartite mirco- and macroergonomic analysis of human-organization-technology interfaces . International Journal of Industrial Ergonomics, 4: 101-115.
28.
Meshkati, N., 1989d. Self-organization, requisite variety, and cultural environment: three links of a safety chain to harness complex technological systems. Invited position paper for the World Bank Workshop in Risk Management (in Large-Scale Technological Operations), Organized by the Work Bank and the Swedish Rescue Services Board, Karlstad, Sweden, Nov. 6-11.
29.
Meshkati, N., 1991. Integration of workstation, job, and team structure design in complex human-machine system: a framework. Journal of IndustrialErgonomics.
30.
Mitchell, C.M., 1987. GT-MSOCC: a domain for research on human-computer interaction and decision aiding in supervisory control systems. IEEE Transactions on Systems, Man, and Cybernetics, 17(1): 553-572.
31.
Mitroff, I.I., 1988. Crisis management: cutting through the confusion. Sloan Management Review, Winter: 15-20.
32.
Munipov, V.M., 1990. Human engineering analysis of the Chernobyl accident. Unpublished manuscript. The USSR Scientific and Research Institute of Industrial Design ( VNIITE ), Moscow.
33.
Naschi, G., 1987. Engineering aspects of severe accidents, with reference to the Seveso, Mexico City, and Bhopal cases. In: P.R. Kleindorfer and H.C. Kunreuther (Editors), Insuring and Managing Hazardous Risks: From Seveso to Bhopal and Beyond. Springer, New York.
34.
Nuclear Safety Review, 1987. International Atomic Energy Agency, Vienna.
35.
Nuclear Safety Review, 1989. International Atomic Energy Agency, Vienna.
36.
Oberg, J.E., 1988. Uncovering Soviet Disasters: Exploring the Limits of Glasnost . Random House, New York.
37.
Perrow, C., 1981. Normal accident at Three Mile Island. Society, July/August: 17-26.
38.
Perrow, C., 1984. Normal Accidents. Basic Books, New York.
39.
Perrow, C., 1986a. Complex Organizations: a Critical Essay (3rd ed.). Random House, New York.
40.
Perrow, C., 1986b. The habit of courting disaster. The Nation , Oct. 11.
41.
President's Commission on the Accident at Three Mile Island, 1979. The need for change: the legacy of TMI. Report of the President's Commission on the Accident at Three Mile Island.
42.
Prince-Embury, S. and Rooney, J., 1988. Psychological symptoms of residents in the aftermath of the Three Mile Island nuclear accident and restart. The Journal of Social Psychology, 128(6): 779-790.
43.
Ramberg, B.1987. Learning from Chernobyl. Foreign Affairs , Winter: 304-328.
44.
Rasmussen, J., 1985. Trends in human reliability analysis. Ergonomics, 28(8): 1185-1195.
45.
Rasmussen, J., 1986. Information Processing and Human-Machine Interaction: an Approach to Cognitive Engineering. North-Holland, Amsterdam.
46.
Rasmussen, J., 1987. The definition of human error and a taxonomy for technical system design. In: J. Rasmussen, K. Duncan and J. Leplat (Editors), New Technology and Human Error. Wiley , New York.
47.
Rasmussen, J., 1989. Human error and the problem of causality in analysis of accidents. Invited paper for the Royal Society Meeting on Human Factors in High Risk Situations, June 28-29, London.
48.
Rasmussen, J., Duncan, K. and Leplat, J. (Editors), 1987. New Technology and Human Error. Wiley , New York.
49.
Rasmussen, J. and Rouse, W.B. (Editors), 1981. Human Detection and Diagnosis of System Failures. Plenum, New York.
50.
Reason, J., 1988. Resident pathogens and risk management. Invited position statement presented at the World Bank Workshop on Safety Control and Risk Management, Washington, DC, Oct. 21.
51.
Reason, J., 1990. Human Error. Cambridge University Press , New York.
52.
Rogovin, M., 1980. Three Mile Island: a Report to the Commission and to the Public, Vol. 1. U.S. Nuclear Regulatory Commission, Washington, DC.
53.
Senders, J., 1980. Is there a cure for human error?Psychology Today, April: 52-62.
54.
Shrivastava, P., 1987. Bhopal: Anatomy of a Crisis. Ballinger , Cambridge, MA.
55.
Shrivastava, P., Mitroff, I.I., Miller, D. and Miglani, A., 1988. Understanding industrial crises. Journal of Management Studies, 25(4): 285-303.
56.
Smets, H., 1985. Compensation for exceptional environmental damage caused by industrial activities. Paper presented at the Conference on Transportation, Storage and Disposal of Hazardous Materials , IIASA, Laxenburg, Austria, July 1-5.
57.
Soviet Report on the Chernobyl Accident, 1986. Data prepared for the International Atomic Energy Agency Expert Conference, August 25-29, Vienna, Austria (translated from Russian). Department of Energy, Washington, DC, August 17.
58.
Speth, J.G., 1984. Statement published in: The Implications of the Industrial Disaster in Bhopal India. Transcripts of the Hearing before the Subcommitttee on Asian and Pacific Affairs of the Committee on Foreign Affairs House of Representatives, Ninety-Eighth Comgress, Dec. 12. U.S. Government Printing Office, Washington, DC.
59.
Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident, 1986. International Atomic Energy Agency, Safety Series # 75-INSAG-1, Vienna.
60.
Thompson, T., 1964. Accidents and destructive tests. In: T.J. Thompson and J.G. Beckerly (Editors). The Technology of Nuclear Reactor Safety. MIT Press, Cambridge, MA.
61.
Union Carbide Corporation, 1985. Bhopal Methyl Isocyanate Incident Investigation Team Report. Union Carbide Corporation, Danbury, CT.
62.
Uth, H.J., 1988. Can Bhopal happen in the Federal Republic of Germany? Some aspects of managing high risk industries. Paper presented at the International Conference on Industrial Risk Management and Clean Technologies, organized by the United Nations Industrial Development Organization (UNIDO) in cooperation with the International Association for Clean Technology (IACT), Nov. 13-17, Vienna.
63.
Weick, K.E., 1987. Organizational culture as a source of high reliability . California Management Review, XXIX: 112-126.
64.
Weir, D., 1987. The Bhopal Syndrome. Sierra Club Books , San Francisco, CA.
65.
Wilson, R., 1987. A visit to Chernobyl. Science, 236 (June): 1636-1640.
