Organizational Failure: Is it Systemic? Part 1

In the following weeks, we will be looking at various case studies of safety incidents that had an organizational failure as one of the root causes. Let’s look inside the Chernobyl incident.

As discussed in this article, the following organizational issues occurred:

  • RBMK reactor design flaw concealed from clients
  • Reactor was scheduled to be tested
  • Reactor was not in condition to be tested according to local engineers
  • Deputy Chief threatened the engineers
  • Deputy Director of the Kurchatov Institute of Atomic Energy released details on the design flaw

The organizational failures listed span more than one organization, (a) the manufacturer/designer of the RBMK and (b) the Chernobyl clients. Within the Chernobyl client, the administration suppressed/punished reasoned dissent. Within the manufacturer/designer of the RBMK, reasoned dissent was suppressed/punished. Decisions were made ignoring engineering/scientific facts at both organizations. To be “systemic”, the dysfunction in one organization needs to be directly related to the other. The relationship between the two is not apparent; a specialist on Soviet organizations would clarify. So with the amount of information we have on this incident from the article, it is not Systemic.