HUMAN FACTORS & ACCIDENT ANALYSIS.
BACKGROUND.
On June 3, 1987, Anatoli Bugorski, a particle physicist working in the Soviet town of Protvino at the Institute for High Energy Physics, suffered an accident during the maintenance of the U-70 Synchrotron particle accelerator. Due to the failure of three separate safety mechanisms, Bugorski was able to move his head directly in the path of the 76 GeV proton beam during his maintenance of the machine, delivering a local dose of roughly 2 to 3 thousand sieverts of radiation directly to the occipital and temporal lobes of his brain, reportedly seeing a flash “brighter than a thousand suns”. Luckily, the stopping power of the proton beam was such that it passed directly through his brain, leaving him with profound radiation damage and epileptic seizures but not enough to prove fatal. Due to the secrecy of radiation programs in the former Soviet Union, Bugorski was prevented from providing details of his accident for over a decade and underwent treatment for his radiation sickness in a secret hospital in Moscow, where he still lives to this day.
This was a solo project, wherein I performed a full accident analysis, examining the moment to moment errors, the systemic errors, and the larger geopolitical context that facilitated such an accident to occur at a high level.
Timeline: 3 Days.
ReSEARCH.
I utilized several methods to provide a rich picture of the incident and its surrounding effectors, including Hierarchical Task Analysis (HTA), SHERPA, Fault/Event Trees, and an AcciMap.
This HTA shows the moment to moment operation of the Particle Accelerator down to its constituent actions, which is necessary to precisely locate errors.
Here, a SHERPA diagram showcases the errors that can occur at any point along the task steps outlined in the HTA, with the probability (P), their criticality (C), their Error Mode (SHERPA standard) and a description of the potential error with its consequences and remediating strategies.
In the fault tree above, there are far too many or-gates, meaning that a single failure in any of these components, even without comm failure, drastically increase the probability of total failure. More importantly, a single failure in any component of the door lock bypasses either of the other safety measures, due to either negligence of the warning light, failure to communicate with control, or both.
RESULTS.
During the peak of the cold war, the USSR commissioned the construction of roughly 60 remote, isolated, and secret “Science Towns”, some were “closed” as they focused on the development of weapons technology, whilst others were “open” as locals had some freedoms outside of the constant vigilance of the Secret Police. The construction commenced in 1964, and concluded in 1967, when beginning to tune the proton beam, CERN’s director stated that more time was necessary, yet the maximum energy level was achieved just 4 days later. The Soviet Union’s desire to become a world superpower, combined with its policy of secrecy, led to rushed construction and a general tight-lipped attitude surrounding the project which negatively affected the workers abilities to perform their duty, as well as dangerous safety regulations.
This AcciMap showcases these high-level issues, and how they directly relate to granular issues leading to the safety failures which resulted in proton beam exposure, these relationships are vitally important to understand as resolving practices higher up in the chain can have a knock-on effect on the work systems present at a lower level.
