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Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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9 Knowledge Management in High-Hazard Industries: Accident Precursors as Practice
Pages 127-136

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From page 127...
... At the fin cc Mile Isl md (TMI) nuclear power pl rat, for example, a combination of events a stuck-open ptessute-telief valve that allowed water levels m the reactor to drop, thus uncovering the radioactive core plus indicators that showed the position of the switch connrolling the valve but not the valve itself plus operator trammg that cautioned operators about overfillmg the n actor with water destroyed a billion dollar unit of the plant and chaps ad the nuclear power industry forever.
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From page 128...
... In response to the TMI accident, the nuclear power indust y created the Institute of Nuclear Power Operations aNPO) to identify precursors, disseminate lessons lea Hod and best practices, and generally ensure that every plant operates with the best knowledge available (and also to forestall further regulation)
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From page 129...
... self-assessment of events to identify root causes of problems and ensure effective corrective actions." She went on to say that self-assessment "should be m ingrained part of every licensee's way of domg business" and that self-assessment would become increasingly mtportrmt as the industry moved "to more performance-oriented regulatory approaches." THE STOCK-AND-FLOW MODEL OF KNOWLEDGE MANAGEMENT Traditional knowledge management is a cotnbinnion of maitttaitttttg repositones of explicit information and expert know-how organized by professional discipline. Examples of explicit information include databases, procedural m~muals, drawings, and planning documents.
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From page 130...
... In such cases, success depends upon the personal involvement of knowledgeable individuals and personal networks that connect accountable investigators with knowledgeable experts. Industries such as nuclear power recognize the importance of personal contacts in the dissemination of best practices, experience with precursors, and so forth.
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From page 131...
... Nearly all high-hazard organizations conduct investigations of problems as part of their corrective-action programs, which sta t with the reporting of problems and continue with the investigation of facts and opinions, the attribution of causes, the generation of insights and recommendations, the implementation of interventions to improve performance, and the verification that these interventions are camed out and produce the expected results (Ca roll, 1995, 1998; Carroll et al., 2001; van der Schaaf et al., 1991)
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From page 132...
... operators firing heater tubes m such a way that the hottest temperatures were located away from the instruments designed to detect danger and (2) the presence of residual coke (coal dust)
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From page 133...
... . In our research on incident investigation teams in nuclear power plants, we assumed that teams that used root-cause analysis to make deeper investigations of precursor events would generate more knowledge and that organizations would implement more effective changes that would improve performance.
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From page 134...
... In managung knowledge about accident precursors, organizations must attend to the local nature of problems and the knowledge that must be brought to bear to address them, as well as to the global nature of what is teamed and what may be needed at other times in other locations. In addition, they must consider knowledge not only as a stock of information, but also as providing the capability of inquinng, imagining, bridging bound die i, building networks of trustmg relationships, and taking action.
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From page 135...
... Orgamzanonal 3ebavim and Human Decision P'ocesses 82:45 59. Hansen, M.T.
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From page 136...
... Strategic Mtntgement Jotmnai 17: 27 43. v m der Schaaf, T.W., D.A.
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Key Terms

  • organizational learning
  • power industry
  • accident precursors
  • investigation team
  • weak ties

  • investigation teams
  • heater tubes
  • power plant
  • build shared
  • van der

  • der schaaf
  • precursor events
  • explicit information
  • root causes
  • human decision

  • personal contacts
  • incident investigation
  • improve performance
  • practice model
  • avoid accidents

  • precursor event
  • mental models
  • swiss cheese
  • decision processes
  • capabilities model

  • pipe failure
  • information include
  • firing heater
  • investigations provide
  • safety culture


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