Industrial accidents system problems causing

Investigations of industrial accidents reveal that most are caused by human error. The twentieth century s worst industrial disasters—Bhopal, Three Mile Island, and Chernobyl—helped clarify the complex chain of system problems that lead to human error. System problems are problems caused by a process system with built in design and operating deficiencies. The accidents provided numerous checklists and case studies for control room and equipment design. A partial list of some of the problems found at the industrial sites mentioned above are ... 

Then came the behaviorists and the management systems people, who have had a significant influence on the safety profession. Their premises are based on the belief that about 90% of all industrial accidents are caused primarily by employee unsafe acts. Some safety professionals, being greatly influenced by those who profess that the worker is the problem, give minimum attention to the influence of design and engineering decisions on incident causation. 

The basic premise of behavior modification programs is that the primary cause of accidents is worker error. This blame-the-victim concept provides little opportunity for effective accident prevention. Behavior modification does not focus on the fundamental safety problems that we face in the continuous process industry. For example, it does not address the need to change the dangerous contractor system or the unsafe practice of running plants far beyond their safe design limits, (p. 2)... 

Health care s fear-based culture has thwarted exploration of weaknesses in the system s work processes, causing the industry to lose rich information about how individuals, technical work, and organizational processes interact. When accidents and near misses are thought of as the symptoms of an underlying problem, they become sources of information and valuable tools to understand how a system functions. Accidents and near misses are useful tools that help define the margins of risk and safety and help us to learn about how harm can be prevented (Amalberti, 2001). 

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