The Inevitability Of Organisational Accidents

Normal accidents are very closely linked to risk society. As our culture takes on new, more advanced technologies and

Instead we can focus on the reason why the person makes the error, and how to reduce the risk of that error to be happening again. Not only that, knowing that making error is humanist can create an environment where individuals are confident that they can report errors or close calls (“near-misses”) without fear of retribution CITATION. For example, if the hospital which the nurse who did a med error is having a culture of safety, the nurse would have no reason to fear of fault, shame, and discipline about the error. She instead should be comfortable to report the error right away to be taken care of, and let the hospital team analyzes the error and find out how to mitigate or prevent future

This caused reactors 1 through 3 to go into a meltdown and it created a situation where Japan was on the brink of a major environmental disaster. To fully understand the different events there will be a focus on: factors that caused the meltdown, why this did not impact the other three reactors, the consequences, who is responsible and how these incidents can be prevented in the future. Together, these elements will highlight the underlying effects of this disaster and its impact on the region. ("Fukushima Accident")

As a collaborative case study, we analyzed the American Airlines Flight 1420 accident using the SHELL Model. The SHEL Model was developed by a Professor Elwyn Edwards in 1972 and it was later modified to the SHELL Model by a human factors consultant named Frank Hawkins. We can see all the human factors that were involved in the accident utilizing following aspects software, hardware, environment, liveware and liveware. The National Transportation Safety Board (NTSB) conducted a thorough investigation and determine that the American Airlines Flight 1420 was a runway overrun accident caused by human factors.

In this paper examples of two different types of organisations were presented and their response to a natural disaster illustrates how sometimes Risk Management processes are not enough to save an organisation from unforeseen adversities. The disaster at Fukushima Daiichi is the second worst nuclear accident in history (Qiang, Xi, Xu, Chong 2013). Even though arguably it could have been avoided, it led to a near universal loss of faith in nuclear energy.

The Fukushima disaster was caused by an earthquake and its following tsunami which caused a failure in the backup systems (World Nuclear Association, 2016). The tsunami knocked out the generators that powered the cooldown processes for three of the Fukushima power plants which caused the radiation leaks and other complications. Consequentially, the disaster was initially classified as a level 5 on the INES scale. Further investigation after the disaster was under control changed it to a level 7 disaster, the highest level on the INES scale. The estimated radioactive releases were about one tenth of Chernobyl, the worst nuclear disaster in history.

The Institute of Medicine (IOM) report To Err is Human (2000) defines patient safety, "as the prevention of harm caused by errors" (IOM, 2000, p. 57). Errors as defined by the IOM (2000) is the "failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim" (IOM, 2000, p. 57). Although not stated in the definition, errors are unintentional and do not have to result in harm of fatalities.

The human factor approach of Reason defines errors according to two types of failure: active and latent failure, with adverse events at times involving a combination of the two. Active failures are defines as “unsafe acts (i.e. errors and violations) committed by those at the human system interface”.20-22 Active errors occur at the level of the operator, and their effects are felt almost immediately. This is sometimes called the sharp end.20-22 Staff actions at the (sharp end) of patient care may involve slips (e.g. picking up the wrong syringe), cognitive failure (e.g. memory lapses or misreading of information), and violation (deviation from standard procedures or processes). Latent failures stem from decisions, essentially made by management and more senior clinicians within the healthcare setting, which provide conditions in which unsafe acts occur (e.g. inadequate system of communication; poor rostering of staff; inadequate supervision; understaffing) and also weakness in defenses (e.g.

Accidents that result from the confluence of these two attributes are considered “normal accident” as they are inevitable, given the level of complexity and tight coupling inherent in the system (Perrow, 1999).

One of the myths of disaster that was surprising to me is the organizational level myth of role abandonment. The view that organizations suffer personnel shortages is opposite of what you see during a disaster. If we take Hurricane Matthew for example, multiple organizations actually did everything in their power to remain open and be able to aid in any type of response and recovery operations. Lowe’s in Jacksonville was open and running on back-up generators since the storm has passed. The manager, when I ask, told me that it was not mandatory for his workers to come in but had the option of attending work after the storm. Local pizza delivery restaurants were delivering free pizza to emergency workers around the county as well as shelters

‘A general view of accident causation in complex systems’, in Human Error, Cambridge University Press, Cambridge.

On March 11th, 2011, the northern section of Japan was hit by a 9.0 magnitude earthquake, followed by a 15 meter tsunami, causing the death of over 15000 people. (Spacey) Even though the earthquake and the tsunami caused a tremendous amount of deaths in the northern region of Japan, the meltdown of the Fukushima nuclear power plant caused a severe damage to northern Japan’s ecosystem that people still cannot go back to their homes; despite it is 4 years after the disaster. After the earthquake, the tsunami destroyed the power supply used by Fukushima’s three nuclear power stations, causing severe levels of meltdown to be occurred inside the reactors in the timespan of 3 days. It was not until 2 weeks after the tragedy, when the reactors were finally stabilized, and took several months to approach what is called a “cold shutdown condition”, in which the fission in the reactors are completely stopped.(Fukushima A)

Normal accident theory and Swiss cheese model are influential models in studying system accident causation. This paper is going to help us to gain understanding of both models and to critically compare them. The first part of the study is an introduction of the both models. In the second part, Three Mile Island nuclear accident will be taken as an example to see how the models analyse causations of an accident. In this part, the fact of the accident will be presented first, then normal accident theory and Swiss cheese model will be invited to identify the causes of the accident respectively. The evaluation and comparison of the two models will be discussed in the final part. Both models conclude that accidents are

EXECUTIVE SUMMARY — Operational failures occur within organizations across all industries, with consequences ranging from minor inconveniences to major catastrophes. How can managers encourage frontline workers to solve problems in response to operational failures? In the manufacturing industry, the setting for this study, operational failures occur due to an internal constraint which is the over use of one major machine. Using data reported from both the production and sale teams, the researcher found that problem-solving in response to operational failures is influenced by both the downtime posed by the constraint and the extent to which the organization incurs a lost. Findings can be used by the organization to increase the management awareness of the extent to which downtime affects the operation process and ways by which improvement can take place.. Key concepts include:

“An accident can be defined as the unplanned, uncontrolled event which has led to or could have led to injury to people, damage to plant, machinery or the environment and/or other loses.” Accident also can be defined as unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury. It is terrifying and terrible with the explosive accident.