4.7 Article

Sociotechnical systems, risk management, and public health: comparing the North Battleford and Walkerton outbreaks

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RELIABILITY ENGINEERING & SYSTEM SAFETY
卷 80, 期 3, 页码 253-269

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ELSEVIER SCI LTD
DOI: 10.1016/S0951-8320(03)00052-8

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risk management; system safety; cognitive engineering; human error; accident analysis; complex sociotechnical systems; public health; water distribution systems

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Accidents in different complex sociotechnical systems are rarely compared using the same theoretical framework for risk management. We conducted a comparative analysis of two Canadian public health disasters involving drinking water distribution systems, the North Battleford Cryptosporidium parvum outbreak in April 2001 and the Walkerton E. coli outbreak in May 2000. Both accidents resulted from a complex interaction between all levels of a complex sociotechnical system. However, the low-level physical and individual factors differed in the two cases, whereas,the high-level governmental and regulatory factors tended to be the same. These findings may have implications for the design of public policies to minimize risk in complex sociotechnical systems. (C) 2003 Elsevier Science Ltd. All rights reserved.

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