Visualising the Relationship between Human Error and Organisational Failure

摘要

Managerial 'failure' plays an important role in major accidents and incidents. Operators have been authorised 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 organisational failure and operator error. One explanation for this is that tools and techniques, which have been developed to analyse human and system failures, cannot easily be applied to reason about organisational problems. This paper argues that Fault Trees help to visualise the ways in which organisational failures create the necessary preconditions for human failure. This approach is also used to focus on the organisational problems that can exacerbate the consequences of those errors in the aftermath of an accident. It is argued that too much attention has been paid upon human errors in the causes of accidents and not enough attention has been paid to organisational failure in post-accident events. 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.