Ola Ploch

Technological causes of organizational crises – The Chernobyl disaster

There exists a long standing debate on the origins of reliability and accidents, between the two
schools “High Reliability Theory” (HRT) and Normal Accident Theory” (NAT). In this
report the two articles “The Limits of Safety: The Enhancement of a Theory of Accidents” by
Perrow, and “Normal Accident Theory versus High Reliability Theory: A resolution and call
for an open systems view of accidents” by Shrivastava, Soupar and Pazzaglia will be applied
to investigate “technological causes of organizational crises” to the Chernobyl disaster in
1986 (Blockbook, 2010/ 2011). The main aspects about the theories NAT and HRT discussed
in the articles will be briefly worded, and the reasons for this serious accident will be shortly
summaries, to analyze how the two theories would explain the Chernobyl accident.

Perrow (1994) explains NAT as a pessimistic view that states, no matter what organizations
do to prevent accidents, they are inevitable and will occur sooner or later. Mayor accidents
will emerge in organizational systems, when they are tightly coupled and complexly
interactive. The former suggests that small mistakes can collude in unexpected ways, and tight
coupling will lead to a cascade of growing large failures, because they cannot be isolated or
contained, and there is no slack time to intervene in time. The later presumes that systems can
have failures, which are independent and insignificant in itself, but can lead to accidents,
because they interact in incomprehensible and unexpected ways, so that even safety systems
cannot help. Furthermore, Perrow presents HRT as a positive view, which describe that
organizations can contribute substantially to the prevention of accidents. Learning from prior
regulatory and operating mistakes, empowering lower levels in organizations, and putting
safety first, can make risky systems safe. Cognitive limitation by humans are admitted by this
theory, but declares that organizations are rational and have highly formalized structures that
are concentrated on consistent and clear goals like safe operations, which compensates for this
weakness. The theory identifies four critical causal factors, which are the reason for positive
safety records: organizations learn from trial and error, high reliability cultures arise,
increased redundancy in technical and personnel safety measures, and organizational leaders
and political elites put reliability and safety first.

Although NAT revel stronger empirical support, there is an persistent debate, which is tried to
be resolved by Shrivastava at al.. He concentrates on the time aspect of NAT and HRT. Nat
focuses on key elements of organizational structure and on circumstances at the particular
time of an accident. Whereas, HRT concentrates on the period leading to the point of accident
and on the processes, which are related to a dynamic situation. Therefore, according to
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Shrivastava et al, the theories diverge, because they regard the accident phenomenon at
different points in time, but are not contradictory.

The Chernobyl accident was a nuclear disaster that occurred on 26 April 1986 in Ukraine, and
is considered as the worst nuclear power plant causality in history. The explosion of a reactor
killed 31 people instantly and approximately 15,000 to 45,000 more through radioactive
contamination, which brought about birth defects, cancer, disabilities and leukemia. Within a
couple of days, radioactive levels had jumped across Asia, Europe, and Canada, and five
million individuals were exposed to radiation around the world. A safety test for testing a
turbine had to be accomplished by the engineers of Chernobyl, in which a reactor had to be
cooled down and power had to be reduced by 50%. For this purpose the emergency cooling
system was turned off. One violation of the regulations was that the reactor power was
reduced, and retained decreasing to 1%. In such circumstances the reactor works unstable and
gases develop that poison the reactor. Another violation was that control rods were removed
by the chief engineer Dyalov, to increase power again, although stopping this experiment by
letting the reactor go cold would have been the only approved solution. Thereby the disaster
would have been averted. Unfortunately, the cooling water pumps were turned off once the
reactor stabilizes and gains power again. On ground of the self-amplifying effect, reactivity
and heat rose exponentially and the explosion was the unavoidable result.

The Chernobyl disaster can be explained by both the theories partially. NAT is a justified
explanation, since the interplay of control rods, cooling water, and especially the exponential
behavior of the reactor power are highly complex and difficult to understand. As investigated
by NAT one single mistake is mostly not enough to convey an accident, only the
unpredictable interaction of different variables can cause it to happen. It might probably have
been sufficient to avert the Chernobyl disaster, when only the water cooling system was not
turned off, as the reactor stabilizes, or when the controlling rods were still available.
Additionally, this system is tightly coupled. There is barely any slack time, because power
and heat are rising exponentially in this nuclear plant, and there exists no simple on/off
button. For example, it was already too late, when the workers started dropping control rods
into the reactor, because they realized that it was heating up too fast. NAT claims that
disasters like the Chernobyl case will occur in the future further on, because all these
happenings were not predictable due to tight coupling and high complexity.

Potential for human failure is incorporated in HRT, which actually causes the accident to
happen. A couple of false choices were made, and the employees became lazy due to
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overconfidence and followed the safety regulations very sloppy. A rational organization could
make up for the several human mistakes, if the employees would have complied with the
safety instructions. In addition, neither for the soviet politicians nor for the conductors of the
experiment was safety the first priority. Furthermore, the US and Soviet governments hided
all foregone errors and failures made by nuclear accidents, which prevented the workforce
form learning. Further, there was no empowering of lower workforce in the Chernobyl case.
Due to his young age, little experience, and the risk of directly losing his employment, a
control engineer did not feel reliable to disagree the instructions, even though he knew that
Dyatlov´s decision was incorrect. All things considered, this tragedy could have been averted,
if the prior mentioned causal factors would have been existent, as the theory suggests.

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Ola Ploch

References:

Perrow, C. (1994). The limits of safety: The enhancement of a theory of accidents. Journal of
Contingencies and Crisis Management, 4, 212-220.

Shrivastava, S., Sonpar, K., & Pazzaglia, F. (2009). Normal accident theory versus high
reliability theory: A resolution and call for open systems view of accidents. Human Relations,
62, 1357-1390.

Blockbook, Chernobyl Case (Appendix 2)