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Extra resources for People in Control: Human Factors in Control Room Design (IEE Control Engineering Series, Vol. 60) (I E E Control Engineering Series)
In both these examples, it becomes apparent that there were a number of facets of the situation that led to the accident. Some of these were already present when the accident occurred and some were created on the day. g. Bhopal, Challenger, Chernobyl, King's Cross and the Herald of Free Enterprise have indicated similar findings (see Reason, 1990; O'Hare, 2001). A medical analogy has been used to refer to the problems that already exist in the system as 'resident pathogens'. For most of the time, these pathogens are kept in check by other parts of the system - similar to the immune system protecting the body from viruses.
These may result from latent failures resulting from poor design, insufficient training, inadequate procedures, system design (hardware and software), regulatory, management and operational failures, as well as communication difficulties and maintenance activities. A further difficulty is deciding how far back in the time frame to go, since there may be resident pathogens present in the system for many years that are of no consequence until they become combined with other failures. For example, the problems with the quality of the rail track at Hatfield may in fact result partly from the lack of investment in the UK railway system that has occurred over many decades.
These internal performance-shaping factors can be addressed via selection and recruitment procedures, and training programmes. As an example, the workers should be trained to admit the possibility of making an error and to acknowledge it when they do. Open-reporting systems such as this allow the management to find out where the errors are being made and to address the situation before an accident or incident occurs. An extension of this is the no blame reporting system as found in the avionics environment where 'no blame' is attached to an admitted mistake in contrast to one that is subsequently found out.