The role of situation awareness in accidents of large-scale technological systems

摘要

In the last two decades, several serious accidents at large-scale technological systems that have had grave consequences, such as that at Bhopal, have primarily been attributed to human error. However, further investigations have revealed that humans are not the primary cause of these accidents, but have inherited the problems and difficulties of working with complex systems created by engineers. The operators have to comprehend malfunctions in real time, respond quickly, and make rapid decisions to return operational units to normal conditions, but under these circumstances, the mental workload of operators rises sharply, and a mental workload that is too high increases the rate of error. Therefore, cognivitive human features such as situation awareness (SA)-one of the most important prerequisite for decision-making-should be considered and analyzed appropriately. This paper applys the SA Error Taxonomy methodology to analyze the role of SA in three different accidents: (1) A runaway chemical reaction at Institute, West Virginia killing two employees, injuring eight people, and requiring the evacuation of more than 40,000 residents adjacent to the facility, (2) The ignition of a vapor cloud at Bellwood, Illinois that killed one person, injured two employees, and caused significant business interruption, and (3) An explosion at Ontario, California injuring four workers and caused extensive damage to the facility. In addition, the paper presents certain requirements for cognitive operator support system development and operator training under abnormal situations to promote operators' SA in the process industry. (C) 2015 The Institution of Chemical Engineers. Published by Elsevier B.V. All rights reserved.