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Don't Be Fooled by the "World's Highest Standards":
Thinking about the Safety of Socio-Technical Systems

Akinori Komatsubara
Professor, Faculty of Science and Engineering, Waseda University

1. Society Expects Zero Accidents

The collapse of TEPCO's Fukushima I Nuclear Power Plant-a plant that was supposed to be secure against safety threats through its measures of "stopping," "cooling" and "containing" them-brought home the realization that there is no such thing as absolute safety. Yet, because of this same event, the Japanese people are unable to accept the fact that severe accidents can occur at nuclear power plants. This mentality makes sense when we consider the large numbers of residents who were subjected to unbearable hardships because of the spread of radioactive materials, and the burden of the remaining clean-up work that will fall to the next unborn generation and, perhaps, the generation after that.

The blame, however, cannot be placed on the generation of nuclear power. It is an undeniable fact that nuclear power provides us with stable, low-cost electricity, which complicates the situation. Modern life would be impossible without electrical power. Virtually no one, I imagine, would want to experience a downgrade in their current way of life. Rather, what we want is for our lives to be even richer and more convenient than they are now. To accomplish that, we will need a lot of electrical power; understandably, however, we would like to avoid nuclear accidents at all costs. But the alternative-the generation of electricity through the burning of fossil fuels-produces massive emissions of CO2 and has been increasing our trade deficit due to fuel imports. Once power companies are no longer able to cut costs, they will have to increase electricity prices, and this, in turn, will surely have a negative impact on the economy. There are high expectations for natural energy, the potential savior of our energy problems, but, unfortunately, it is not yet a stable source of electricity. In short, while it would be best if we could avoid nuclear power altogether, the reality is that Japanese society has little choice but to rely on nuclear power for the time being.

You have to take the risks if you want to reap the benefits. This principle is not limited to nuclear power generation alone. Safety is not free. You have to invest in it. This does not mean, however, that money should be spent indiscriminately; it needs to be invested in a wisely-prioritized fashion.

Modern society is, after all, a fragile thing, like a glass sculpture supported by various socio-technical systems. Socio-technical systems are large-scale systems that form the infrastructure of society; they include air and rail transportation, information and communication networks, medical services and public utilities like electricity, gas and water. These systems are expected to provide a stable supply of services-any disruption in which can have a considerable impact on residents and throw their lives into chaos. Consider, for example, the importance of train schedules; if a commuter train gets off schedule, not only will its passengers immediately be seriously inconvenienced, but some may be unable to board their flights in time and, as a result, miss out on important business opportunities. The most serious kinds of disruptions are called "accidents." When an accident occurs, a service is suspended for a long period of time and an enormous amount of money, which could have been better spent on other things, must be set aside to control the situation. When accidents results in injury or death, the victims and their families experience indescribable pain and suffering, and those involved in the incident may be investigated for criminal responsibility. To avoid these situations, business operators must, as a matter of course, take measures to provide reliable services, or, in other words, implement a safety management system, rather than acting in a haphazard way. At least, that is the theory, but what actually happens in practice?

2. What Factors Disrupt Stability?

So what should business operators do to implement effective safety management? To get right down to the point, they should take steps to prepare for and handle events that could pose a threat or "hazard" to the reliability of their services. These hazards are typically divided into the following five categories.

∙Natural hazards: These are natural disasters such as hurricanes, earthquakes and heavy snowfall. The Keihin Kyuko derailment accident (September 25, 2012) and the massive power outage in Hokkaido that was caused by a blizzard (November 27, 2012) are examples of natural hazards. Small animals and other organisms can also pose serious threats, as seen in the phenomenon of bird strikes on airplanes.

∙Social hazards: These are pranks and malicious attacks and acts of terrorism. People who put stones on railroad tracks or enter restricted areas are examples of social hazards to railways. Cyber-attacks, such as the falsification or leakage of data via hacking, have also become serious hazards. Just recently, hackers were able to gain access to and alter Japanese government websites.

∙Technical hazards: These include equipment failure. It is well known that equipment failure is especially common when new machines are introduced, the operational conditions are changed, or old equipment is used. The Sasago Tunnel accident (December 2, 2012), in which the ceiling panels of a tunnel on the Chuo Expressway collapsed, is suspected to have been caused by the aging of the facilities. There are many industries with old equipment and facilities that are due for replacement, and the organizations in these industries need to always be on the alert for these threats.

∙End-user hazards: These are threats that arise when demand outstrips supply. While those of us in Japan made it safely through the summer, there are serious concerns about possible electricity shortages this winter. Large influxes of passengers on railways or patients in medical institutions can pose threats to the overall provision of reliable services in these industries.

∙Human factors hazards: These are so-called "human errors" and violations of rules and regulations, which, I imagine, require no further explanation.

Disaster prevention, in the broad sense of the term, is needed for natural hazards, as are crime-prevention (security) measures for social hazards, technology risk management for technical hazards, the regulation of demand for end-user hazards, and measures to prevent human error for human factors hazards. New forms of these hazards are always emerging. We have even seen the appearance of unprecedented natural hazards, such as "guerrilla rainstorms" (sudden heavy downpours). Thus, we must constantly try to predict new threats or hazards and implement measures against them to ensure they do not catch us off-guard.

An important point to keep in mind here is that the agents performing these predictions and implementing these measures are, in the end, "human." Unfortunately, since human beings lack god-like perfection, we cannot expect them to be infallible. Even if our efforts seem doomed to failure, though, the only option we have is to try to improve our safety by leveraging our human intelligence and responding to threats as well as we can. If there are gaps in our defenses or we are na誰ve in our approach, however, a threat may strike without warning, resulting in a "man-made disaster." Hence the controversy over whether the Fukushima Daiichi nuclear disaster was really a natural disaster or a man-made disaster.

3. Leveraging Human Intelligence

The process of leveraging human intelligence starts with developing a strong imagination. In addition, flexible organizations are needed, which can quickly implement the safety measures that are proposed as a result of leveraging human intelligence. However, when safe conditions persist over a long period of time and increasing generations of employees are hired to operate the existing system instead of develop it, many organizations lose their ability to imagine potential threats and, if their employees do warn them of any, make no attempt to address such threats in a direct, prompt manner. Before long, both the organization and its personnel become rigid and lose their ability to ward off threats.

Once again, we need to rethink the concept of "human-dependent safety." This may require strategies, rather than techniques, for building safety systems.

4. The Seductive Idea of the "World's Highest Safety Standards"

Ever since the Fukushima Daiichi nuclear disaster, you hear expressions like "we aim to achieve the world's highest safety standards" wherever you go in Japan. While such expressions sound brave and comforting, they are harmful to discussions about safety that involve theories of technology.

Let me illustrate what I mean with an example. Suppose that a brown bear is being kept at a zoo. If the bear's cage is somewhat stronger than the cages of any other zoo in the world, it will automatically qualify as the world's safest cage. But would that be enough? I think my readers will be able to understand the apprehension behind this question. With the bear's strength or any of the threats mentioned above, the cage may break down in an instant even if it is the "world's safest cage." What needs to be discussed is the bear's strength and the other potential threats, how to construct a solid safety system that can withstand these threats, and how to create a flexible organization that can implement this safety system. In other words, we need to build up layers of preparedness to provide a stable service. If you skate on a frozen lake, the ice will not break if you insist that the thickness of the ice extend all the way to the bottom. That's the kind of system-supported safety we want. Competing with others over whose lake has the thickest ice is beside the point when we are discussing the safety of socio-technical systems. These discussions are philosophies that can serve as a foundation for the leveraging of human intelligence-not simple word games.

When it comes to the safety of socio-technical systems, we cannot allow ourselves to be misled by seductive statements like "the world's highest standards." For, if we fall for these statements, we may have to face another incident on the scale of the Fukushima Daiichi nuclear disaster.

Akinori Komatsubara
Professor, Faculty of Science and Engineering, Waseda University

[Profile and main works]
Professor Komatsubara was born in 1957. He is a professor in the Department of Industrial and Management Systems Engineering, School of Creative Science and Engineering, Faculty of Science and Engineering, Waseda University. He graduated in Industrial Engineering and Management from the Faculty of Science and Engineering, Waseda University and went on to earn a Ph.D. in Engineering from the same university. Prof. Komatsubara specializes in Human Life Engineering. He is interested in studying the following areas from the perspective of natural human behavior: the prevention of human error, the improvement of on-site non-technical skills, the prevention of the misuse of products and the enhancement of product usability, and the construction of management systems that address these issues. He has served as a member on safety committees for government agencies, private companies and other organizations. Prof. Komatsubara is the author of books such as Human Error [Hyuuman Eraa] (Maruzen, 2008) and the translator of books such as Safety at the Sharp End: A Guide to Non-Technical Skills [Genba Anzen no Gijutsu: Non-tekunikaru Sukiru Gaidobukku] (R. Flin et al., Kaibundo, 2012).