Cognitive Systems Engineering Analysis of the JCO Criticality Accident

摘要

The JCO Criticality Accident is analyzed with a framework based on cognitive systems engineering. With the framework, analysis is conducted integrally both from the system viewpoint and actors viewpoint. The occupational chemical risk was important as safety constraint for the actors as well as the nuclear risk, which is due to criticality accident, to the public and to actors. The inappropriate actor's mental model of the work system played a critical role and several factors (e.g. poor training & education, lack of information on criticality safety control in the procedures and instructions, and lack of warning signs at workplace) contributed to form and shape the mental model. Based on the analysis, several countermeasures, such as warning signs, information system for supporting actors and improved training & education, are derived to prevent such an accident.