Managerial 'failure' plays an important role in major accidents and incidents. Operators have been authorized to deliberately remove safety mechanisms. They have also been instructed to guide application processes into dangerous operating environments. Given the consequences of such intervention, it is surprising that so little is known about the relationship between managerial failure and operator error during major accidents. One explanation is that most tools and techniques, which have been developed to analyze human and system failures, cannot easily be applied to represent and reason about organizational problems. In a first attempt to address this problem, I will show that Fault Trees can represent the ways in which organizational failures create the necessary preconditions for human failure.
I also hope to demonstrate that cognitive explanations provide a very limited view of human `error' in major accidents and incidents.
A collision between a Maryland Commuter train and an American National Railroad Passenger Corporation train on February 16th, 1996 is used to illustrate this argument.
For more information contact: johnson@dcs.gla.ac.uk