Who is to blame, the operator or the designer? Two stages of human failure in the Chernobyl accident

This paper analyzes the causes of the Chernobyl power plant accident on April 26, 1986. Therefore, two stages of human failure are investigated by two separate system dynamics models. This paper finds that the accident was caused by the combination of human failures in (stage 1) the design of the reactor and (stage 2) on-line operations. The value of the conducted approach lies in the combined view on the two stages of human failure. The impact of the gained insights on organizational improvement initiatives is discussed.