A Discussion of Institutional Failure and Its Importance to Nuclear Safety

Abstract

In this paper, we will attempt to show from a review of selected past accidents, both nuclear and non-nuclear, that there exists a class of failures which is important enough that it should be identified and dealt with as a separate group in its own right. We have called this class of failures "institutional failure". We define it ingeneral terms as being the absence or malfunction of some corporate activity which is necessary for nuclear safety. Such absence or malfunction results from human error (in the general sense) where the error can be remote in time, place and corporate hierarchy from the point at which the physical threat to safety occurs.We will offer evidence in support of both our contention that this phenomenon ex1sts and our definition of it and we will distinguish it from other recognized classes of failure. The operation of institutional failure in past accidents will be indicated and relevant recent literature will be cited and discussed. We will also identify some mechanisms which exist in one organization (Ontario Hydro) and which could be applied to the management of institutional failure and its causes.While our work is preliminary, we are able to draw some limited conclusions about institutional failure and how it might be dealt with.