Accident Analysis by Using Methodology of Resilience Engineering, High Reliability Organization, and Risk Literacy

摘要

The good cases of resilience response are observed in individual base and organizational base as below: The effectiveness of insight on accident cases (inundation in Madras, 9.11 terrorism-B.5.b. order) and of the risk evaluation, Decision of continuation of sea water infusion (individual base), Reflection of the experience on Chuetsu-Oki Earthquake, Improvement of seismic building which is equipped emergency power source system and air conditioning system (organizational base), Deployment of fire engines (organizational base), The effectiveness of command system in ordinal time (on-site of organizational base), and Support by cooperation companies and manufacturers (designers and site workers of organizational base). It is important to 'establish the feedback system on organization learning in ordinal time' and it means that it is important to establish the system admitting violation of order. The decision at on-site are given priority than other ones. The representative example is the decision of sea water infusion continuation which was given priority at on-site, even though the official residence and the main office of Tokyo Electric Power Company had ordered to stop the infusion.