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On August 20, 1969, two Penn Central commuter trains collided head-on near Darien, Connecticut, killing four and injuring 43. That tragedy 45 years ago began the NTSB's call for development and implementation of Positive Train Control (PTC) systems. Since then, the NTSB has issued almost 50 PTC-related safety recommendations and has included PTC on its Most Wanted List every year from its inception in 1990 until enactment of the RSIA. Unfortunately, despite some progress in the four decades since that original recommendation, PTC preventable train collisions still occur. In this paper, we identify human and organizational factors that affect a successful PTC implementation and evaluate the application of High Reliability Organizing (HRO) characteristics in the implementation of this safety system.

March 5, 2020Disclaimer: Editor's note: This article was originally published in the National Academy of Medicine Perspectives on March 5, 2020. It was is the 5th most read NAM Perspective pape...

This study applies the AcciMap methodology, which was originally proposed by Professor Jens Rasmussen (1997), to the analysis of the tragic Sewol Ferry accident in South Korea on April 16, 2014, which killed 304 mostly young people and is considered as a national disaster in that country. This graphical representation, by incorporating associated socio-technical factors into an integrated framework, provides a big-picture to illustrate the context in which an accident occurred as well as the interactions between different levels of the studied system that resulted in that event. In general, analysis of past accidents within the stated framework can define the patterns of hazards within an industrial sector. Such analysis can lead to the definition of preconditions for safe operations, which is a main focus of proactive risk management systems. In the case of the Sewol Ferry accident, a lot of the blame has been placed on the Sewol's captain and its crewmembers. However, according to this study, which relied on analyzing all available sources published in English and Korean, the disaster is the result of a series of lapses and disregards for safety across different levels of government and regulatory bodies, Chonghaejin Company, and the Sewol's crewmembers. The primary layers of the AcciMap framework, which include the political environment and non-proactive governmental body; inadequate regulations and their lax oversight and enforcement; poor safety culture; inconsideration of human factors issues; and lack of and/or outdated standard operating and emergency procedures were not only limited to the maritime industry in South Korea, and the Sewol Ferry accident, but they could also subject any safety-sensitive industry anywhere in the world.

Failures in complex technological systems could have multiple dire aftermaths, including many deaths and injuries. These events, such as nuclear accidents, pose serious threats and long-lasting health and environmental consequences to workers, the local public, and possibly the whole country and neighboring regions. Such failures, given interconnectivities and interdependencies, could also have spillover effects and threaten the integrity of other systems operating in the same area. There is an essential need for effective integration and interoperability among multiple emergency response agencies, possibly from different countries, in the case of an accident in a safety-sensitive industry that causes the release of hazardous materials or contaminants. This article proposes a generic integrated system-oriented model to address this urgent need. It has been applied to the Persian Gulf area and its waters as a case study because of the existence of multiple co-located, safety-sensitive industries such as nuclear power generation, offshore oil and gas drilling, seawater desalination, and seafood harvesting. The Persian Gulf region and its ecosystems are highly vulnerable, and the countries around the Gulf are tightly interdependent, with an urgent need for cooperative emergency response planning. The Black Sea and other semiclosed, water-based ecosystems can also benefit from this model.

Objective: The aim of this study is to identify the interdependencies of human and organizational subsystems of multiple complex, safety-sensitive technological systems and their interoperability in the context of sustainability and resilience of an ecosystem. Background: Recent technological disasters with severe environmental impact are attributed to human factors and safety culture causes. One of the most populous and environmentally sensitive regions in the world, the (Persian) Gulf, is on the confluence of an exponentially growing number of two industries—nuclear power and seawater desalination plants—that is changing its land- and seascape. Method: Building upon Rasmussen’s model, a macrosystem integrative framework, based on the broader context of human factors, is developed, which can be considered in this context as a “meta-ergonomics” paradigm, for the analysis of interactions, design of interoperability, and integration of decisions of major actors whose actions can affect safety and sustainability of the focused industries during routine and nonroutine (emergency) operations. Conclusion: Based on the emerging realities in the Gulf region, it is concluded that without such systematic approach toward addressing the interdependencies of water and energy sources, sustainability will be only a short-lived dream and prosperity will be a disappearing mirage for millions of people in the region. Application: This multilayered framework for the integration of people, technology, and ecosystem—which has been applied to the (Persian) Gulf—offers a viable and vital approach to the design and operation of large-scale complex systems wherever the nexus of water, energy, and food sources are concerned, such as the Black Sea.

The removal efficiency of heavy metals from offshore muds is enhanced in the presence of generated chlorine gas (Cl2). The tests showed a high removal efficiency of heavy metals at the anode end of cores after 24 hours of EK application. In the initial tests, high electrokinetic flow potential was achieved; however, high levels of chlorine gas were produced in the high-salinity environments. The process was improved by controlling and maintaining a certain fraction of the chlorine gas (Cl2) in place. The pH was controlled by the chlorine gas maintained in-situ and transported from the anode to cathode. The transports of four heavy metals were evaluated in this study. The chlorine gas can have two impacts on the transport of metals in the system. One is to oxidize the metal ions to a higher oxidation state and the second is to form chloride complexes, which have higher mobility in the system. Determination of oxidation state and the subsequent metal chloride complex are left for future research.

All oil and gas pipeline systems are run by human operators (called controllers) who use computer-based workstations in control rooms to "control" pipelines. Several human factor elements could contribute to the lack of controller success in preventing or mitigating pipeline accidents/incidents. These elements exist in both the work environment and also in the computer system design/operation (such as data presentation and alarm configuration). Some work environment examples include shift hours, shift length, circadian rhythms, shift change-over processes, fatigue countermeasures, ergonomics factors, workplace distractions, and physical interaction with control system computers. The major objective of this paper is to demonstrate the critical effects of human and organizational factors and also to highlight the role of their interactions with automation (and automated devices) in the safe operation of complex, large-scale pipeline systems. A case study to demonstrate the critical role of human organizational factors in the control room of an oil and gas pipeline system is also presented.

A novel technology (electrokinetics) is proposed to improve acidizing operations, i.e., increase the penetration distance. The acid dissolves the carbonates (limestones/dolomites), enlarging the pores and increasing the width of pre-existing fractures. This gives rise to an increase in permeability. The principal acid commonly used is hydrochloric (HCl), which is pumped through tubing. Aqueous solutions of hydrochloric acid (usually 15%) are pumped into the carbonate formations to enlarge the pores and pre-existing fractures. Without application of D.C. current, the penetration distance is usually very short, especially in tight rocks. However, the penetration distance of acid is very short. By applying D.C. current, one can drive the acid for long distances into the formation being acidized.

The common causes of failures of complex technological systems (e.g., nuclear power and chemical processing plants; modern w weapon systems) are analyzed. It is demonstrated that in addition to independent and isolated problems at the individual subsystem levels — workstation (interface), job (task) and team (organizational) structure — there is a serious lack and need for a coherent framework to coordinate these subsystems' formation, as well as their integration, in the context of the total system design. It is proposed and demonstrated that the skill, rule, and knowledge (SRK) model, developed by Rasmussen (1983), is a high-potential and powerful conceptual framework that could be utilized for the integration of workstation, job, and team (organizational) design in the complex human-machine systems.

This paper explores the hypothesis that driver decision-making style influences highway-rail crossing accidents. To investigate this, the authors have designed an analysis of variance experiment with three independent variables: "driver decision style," "driver time pressure" and "intersection complexity." To simulate the driving conditions, the authors identified and videotaped a number of dangerous crossings in downtown Los Angeles. The tapes represented different environmental complexities and time pressures a driver experiences while crossing an intersection. The tapes were played back to the subject drivers. The subjects were classified according to their decision styles. Dependent measures were designed based on a driver's decision to cross the intersection. This paper presents the conceptual approach and the experimental design for this research.

The catastrophic accident at the Union Carbide Corporation's pesticide plant in Bhopal, India (1984) is investigated and its micro- and macroergonomic causes are identified. It is demonstrated that this accident was not prototypical, and there were numerous similarities with respect to the of lack of human factors considerations between the Bhopal plant and other industrial facilities which have had major accidents, including the Three Mile Island nuclear power plant (1979). This analysis can, by extrapolation, be applied as well to many other comparable plants around the world which because of sheer luck and/or coincidence, fortunately, have not had a major accident, yet. It is concluded that only through a proactive, systematic, and integrated micro- and macroergonomically-based policy can one control the safety and ensure the efficiency of the operations of industrial plants and facilities, both in industrialized and developing countries.

Technology transfer, its role in the economic development of developing countries, and factors affecting its success is studied. Numerous studies of appropriate technology indirectly and implicitly indicate that micro- and macroergonomic considerations play instrumental roles in the success of technology transfer projects. Major micro- and macroergonomic considerations of technology transfer are discussed, and it is concluded that only through a proactive and systematic incorporation of these considerations can one ensure the appropriateness, safety, and effective utilization of the transferred technology.