Dynamics and Migration to a High-Risk State

Another change over time that affected safety in this system was the physical change in the separation of the population from the plant. Usually hazardous facilities are originally placed far from population centers, but the population shifts after the facility is created. People want to live near where they work and do not like long commutes. Land and housing may be cheaper near smelly, polluting plants. In third world countries, utilities (such as power and water) and transportation facilities may be more readily available near heavy industrial plants, as was the case at Bhopal. 

The goal of understanding the dynamics is to redesign the system and the safety control structure to make them more conducive to system safety. For example, behavior is influenced by recent accidents or incidents As safety efforts are successfully employed, the feeling grows that accidents cannot occur, leading to reduction in the safety efforts, an accident, and then increased controls for a while until the system drifts back to an unsafe state and complacency again increases. .. 

This complacency factor is so common that any system safety effort must include ways to deal with it. SUBSAFE, the US. nuclear submarine safety program, has been particularly successful at accomplishing this goal. The SUBSAFE program is described in chapter 14. 

One way to combat this erosion of safety is to provide ways to maintain accurate risk assessments in the process models of the system controllers. The more and better information controllers have, the more accurate will be their prcx ess models and therefore their decisions. 

The goal of an accident analysis should not be just to address symptoms, to assign blame, or to determine which group or groups are more responsible than others. 

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