Human factors in large-scale technological systems' accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis
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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