Totalitarian loss of responsibility in an explosives production plant

摘要

One of the largest accidents of communist era in former Czechoslovakia occurred in an explosion production plant in Semtin 26 years ago. Original analysis of the accident concentrated on technical causes and did not look for root causes. Additional root cause analysis showed that the plant's safety management had been decaying and that other layers of causes had lain under the root causes. According to deeper analysis in this article, the event represents an accident that shows the decay of safety management after decades of dispersed ownership in a totalitarian society. We attempt to understand the mechanisms which led the plant into such a state. Their substantial aspects are identified and a model of the development of managers' attitude to safety is constructed. The analysis points at the replacement of ideal managers' behavior in safety management by distorted behavior which is here termed the totalitarian loss of responsibility. Presumably, more accidents with similar backgrounds can be identified in totalitarian surroundings. The analysis shows that the Chernobyl disaster can be considered one of them. Tools that helped deepen the analysis are based on the STAMP model and on the archetypes of safety. The analysis integrates various ideas and models into a single procedure based on the original representation of assumptions about the structure of safety management.