Safety planning and safety culture in the JCO criticality accident: interpretive comments

摘要

In looking at this accident, I would like to concentrate on the relation between safety planning and safety culture. The accident shows a conspicuous mismatch between the farm of safety planning and the operation's culture of safety. Put very simply, the accident shows a damaging absence of requisite imagination, and thus an inability to consider what might go wrong. In what follows I provide the details supporting this observation.