Who is to Blame (Human Failure in Chernobyl) | Who is to Blame (Human Failure in Chernobyl)

Who is to blame, the operator or the designer? Two stages of human failure in the Chernobyl accident

Markus Salgea* and Peter M. Milling

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M. Salge and P. M. Milling: Who is to Blame, the Operator or the Designer? 89
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/sdr
Who is to blame, the operator or the designer?
Two stages of human failure in the Chernobyl
accident
Markus Salgea* and Peter M. Milling a
Abstract
This paper analyzes the causes of the Chernobyl power plant accident on April 26, 1986. There-
fore, two stages of human failure are investigated by two separate system dynamics models. This
paper finds that the accident was caused by the combination of human failures in (stage 1) the
design of the reactor and (stage 2) on-line operations. The value of the conducted approach lies in
the combined view on the two stages of human failure. The impact of the gained insights on
organizational improvement initiatives is discussed. Copyright © 2006 John Wiley & Sons, Ltd.
Syst. Dyn. Rev. 22, 89–112, (2006)
Introduction
This article analyzes the accident at the Chernobyl power plant on April 26,
1986 in order to shed light on the causes of the disaster. Two stages of human
failure are investigated by two separate system dynamics models: (stage 1) the
design and functionality of the Chernobyl reactor; and (stage 2) human failures
in on-line operations. The analyses show that the accident was caused by the
combination of the specific reactor characteristics and infringements of safety
rules. The former aspect is due to the process of graphite-moderated uranium
fission, which tends to increase in reactivity in the case of a malfunction or
faulty operation. The latter can be ascribed to the effect that infringements
which did not cause accidents in the past lead to more violation of safety rules
in the future.
In the next section, the two-stage approach is discussed in more detail. The
third and fourth sections give insights about the process of graphite-moderated
nuclear fission, as well as the functionality and design of the Chernobyl reactor
(stage 1). Subsequent to this, infringements in on-line operations (stage 2) are
analyzed. The paper ends with a brief discussion of the impact of the gained
insights on organizational improvement initiatives.
Two stages of human failure
“Good evening, comrades. As you all know, a misfortune has befallen us—the
accident at the Chernobyl Nuclear Power Plant. . . . It goes without saying
Markus Salge is a
PhD candidate at
Mannheim University,
Germany. He teaches
manufacturing
strategy and system
dynamics courses at
graduate level. His
research focuses on
the introduction of
improvement
initiatives in
industrial
manufacturing by
using the system
dynamics approach.
His research interests
include the change
and transition
processes of industrial
organizations. He was
the organizer of the
Sixth System
Dynamics PhD
Colloquium 2005 in
Boston,
Massachusetts, U.S.A.
Peter Milling is
Professor of
Management. He holds
the Chair in Business
Administration,
Industry and
Operations
Management and is
Director of the
Institute of Physical
and Chemical
Technology
(Industrieseminar),
both at Mannheim
University. His
research interests
focus on business
dynamics, strategies
System Dynamics Review Vol. 22, No. 2, (Summer 2006): 89–112
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/sdr.334
Copyright © 2006 John Wiley & Sons, Ltd.
89
a Mannheim University, Schloss, D-68131 Mannheim, Germany
* Correspondence to: Markus Salge. E-mail: salgem@is.bwl.uni-mannheim.de
Received August 2005; Accepted February 2006

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