ABSTRACT

In his article, Reason (2000) discusses causes of accidents and how investigation of accidents should be done. There he emphasizes the importance of not only analyzing active failures, the unsafe acts committed by people who are in direct contact with the system, but also, and even more importantly, latent conditions which arise from decisions. Accidents are often a combination of active failures and latent conditions. The active failures often act as trigger to the latent conditions, and the whole chain of resulting failures can lead to a severe accident. In an investigation it is therefore very important to consider the latent conditions and not only the active failures, since the accidents would not in many cases have the magnitude as it had without the latent conditions (Reason, 2000). In this study the analysis conducted based on the theory of human error developed by Reason (2000) and the report prepared by Svensson et al. (2010), Wikipedia (2016a & 2016b) and World Nuclear Association (1986).