Complex Systems Safety and Resiliency: Safety Culture, Systems Design & Integration Professor

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(New) CE 599 Course Syllabus

Spring 2015- Thursday 6:30-9:10 PM
Complex Systems Safety and Resiliency:

Safety Culture, Systems Design & Integration

Dr. Najmedin Meshkati


Sonny Astani Dept of Civil/Environmental Engineering

Daniel J. Epstein Dept of Industrial & Systems Engineering

Viterbi School of Engineering


School of International Relations

University of Southern California

Office Location: KAP Bldg, Rm # 240D

Los Angeles, CA 90089-2531

Email: ; Telephone: (213) 740-8765

Introduction and Purposes

This new course is concerned primarily with understanding key determinants of safety and resiliency of complex technological as well as Civil Infrastructure Systems (CIS).  [These systems could also be subjected to risks of natural hazards phenomena and man-made actions.]  They include such systems as the major modes of transportation and their facilities, energy generation (e.g. nuclear power stations), transmission grids and distribution networks, gas and liquid fuels pipelines, refineries, and petrochemical plants. Potential catastrophic breakdowns of these complex systems, which “almost always fail in complex ways”, and often are characterized as ‘low probability, high consequence’, could pose serious threats for workers, the local public, and possibly the neighboring region and parts of the whole country (e.g., Fukushima nuclear accident, March 2011).  Both safety and resiliency of these systems, which is defined as the ability to “prepare for and adapt to changing conditions and withstand and recover rapidly from disruptions”, is a function of the interactions among their composing engineered, human and organizational subsystems.

Course Procedures

Course material will be presented in a variety of ways. These will include: Lectures, chapters from published books; excerpts from US National Academies, US Government agencies and international organizations reports; handouts (published articles and unpublished manuscripts); discussions, case studies and in-class group presentations (applying AcciMap method to different cases), video clips, and guest speakers. Additionally, the instructor may present alternative approaches, theories, models, and points of view that are different from the reading material. While this may not represent personal beliefs, it is often helpful in:

  • Familiarizing the student with different theoretical models used in the discussed subject matters; and

  • Providing the student a chance to examine his/her own studies, experiences, and integrate these with other sources of information.

Breakdown of Course Topics




Reading/ Assignments

Week 1


Introduction, course goals, structure, procedures

Overview of complex systems safety

Total systems design process

Introduction of case studies and group projects (refer to the following list)

Selected chapters from Perrow (1999 & 2007)

Weick & Sutcliffe (2007)

Week 2


Human-Organization-Technological (HOT) Subsystems

Human-systems integration (HSI)

Meshkati (1995)

Excerpts from NRC HSI report: HSI in System Development Process

Week 3


Safety Culture – US NRC, INPO – Part I

US NRC, INPO reports

Week 4


Systems Resiliency – Part I

Deadline: Individual Research Project Proposal

Excerpts from NAS report: Disaster Resilience

Week 5


AcciMap method: Background, examples and applications

AcciMap sources (see the following)

Week 6


Public Policy and Regulatory Issues in Safety and Resiliency – Part I

Rulemaking (design and safety standards)

NAS Fukushima report (2014)

Meshkati & Chin (in press)

Week 7

Case Study 1+AcciMap1 – Group1 Presentation

Lecture: Safety culture – Part II

Case Study 1 material

Meshkati (1999)

Week 8

Case Study 2+ AcciMap2– Group2 Presentation

Lecture: Systems resiliency – Part II

Deadline: Individual Research Project Progress Report

Case Study 2 material

NAS Disaster Resiliency

Meshkati & Khashe (in press)

Week 9

Case Study 3+AcciMap3 – Group3 Presentation

Lecture: Public Policy Part II- Regulatory capture

Case Study 3 material

NAS Fukushima Report

Week 10

Case Study 4+AcciMap4 – Group4 Presentation

Lecture: Public Policy Part III- “Regulatory Accidents”

Case Study 4 material

Regulatory Accidents monograph (handout)

Week 11

Case Study 5+AcciMap5 – Group5 Presentation

Lecture: Public Policy Part IV- Emerging new framework:“The Safety Case”

Case Study 5 material

Meshkati & Chin (in reivew)

Week 12

Case Study 6+AcciMap6 – Group6 Presentation

Lecture: Independent US Federal Safety Agencies (NTSB, CSB, DNFSB)

Case Study 6 material

NTSB, CSB, DNFSB handouts

Week 13

Case Study 7+AcciMap7 – Group7 Presentation

Lecture: New technology integration challenges [Case of the Positive Train Control (PTC) and US railroads]

Case Study 7 material

NTSB Metrolink Chatsworth accident investigation report

Week 14


International cooperation for enhancing complex systems safety and resiliency – Bilateral mechanisms (US State Dept, USAID, NRC, DoE, etc) and multilateral agencies (IAEA, WANO, ICAO, UNIDO, etc.)

Meshkati (2012)

DoE material

DoS & USAID material

IAEA & WANO material

Week 15

Lecture, Conclusion & Wrap-up

Deadline: Individual Research Project Final Report

Case Studies for Group Projects - Major Complex Systems (Industries) Failures

  1. Civil infrastructure systems

    1. Grand Teton dam failure

    2. Hurricane Katrina and levees failure in New Orleans

  2. Nuclear power plants (TMI, Chernobyl, Fukushima, Onagawa)

  3. Electricity Grid (Blackout of August 2003)

  4. Oil and gas pipelines (PG&E San Bruno explosion)

  5. Railroad (Metrolink, Fort Totten)

  6. Chemical Processing plants (Philips Petroleum Plant, Formosa Plastics explosion)

  7. Oil refineries (Tosco, BP Texas City, Tesoro, Chevron Richmond)

  8. Offshore platforms (BP Deepwater Horizon)

  9. Coal mining (Upper Big Branch Mine)

  10. Aviation/Aerospace (Tenerif, Challenger, Columbia, JPL mishaps)

  11. Oil and gas fracking (Denton, TX April 2013 blowup)

Noteworthy complex systems failures in other countries:

China: Wenzhou train accident

India: Bhopal chemical plant accident

Canada: Lac-Mégantic rail disaster

Venezuela: Amuay Refinery explosion

South Korea: Sewol Ferry accident

Turkey: Soma mine accident

Singapore: Nicoll Highway collapse, Ginza Plaza explosion, & Fire onboard MT Stolt Spur
Grading Basis
Grades will be based on the following weighted criteria:
1. Midterm Exam 25%

2. Class participation 10%

3. Group project

(A major case study & applying AcciMap) 40%

4. Individual Research Project 25%

Total 100%

Hybrid, Local Online, or Distance Learning Courses
The course could also be offered on Viterbi’s Distance Education Network (DEN). The Viterbi School has as established distance-education program, and the means for online communication between the instructor and the students, as well as among the students. In addition, VSoE has at its disposal resources for the electronic submission and return of homework and examinations.

Statement on Academic Conduct and Support Systems


Academic Conduct

Plagiarism – presenting someone else’s ideas as your own, either verbatim or recast in your own words – is a serious academic offense with serious consequences.  Please familiarize yourself with the discussion of plagiarism in SCampus in Section 11, Behavior Violating University Standards  Other forms of academic dishonesty are equally unacceptable.  See additional information in SCampus and university policies on scientific misconduct,
Discrimination, sexual assault, and harassment are not tolerated by the university.  You are encouraged to report any incidents to the Office of Equity and Diversity or to the Department of Public Safety  This is important for the safety whole USC community.  Another member of the university community – such as a friend, classmate, advisor, or faculty member – can help initiate the report, or can initiate the report on behalf of another person.  The Center for Women and Men provides 24/7 confidential support, and the sexual assault resource center webpage describes reporting options and other resources.
Support Systems

A number of USC’s schools provide support for students who need help with scholarly writing.  Check with your advisor or program staff to find out more.  Students whose primary language is not English should check with the American Language Institute, which sponsors courses and workshops specifically for international graduate students.  The Office of Disability Services and Programs certification for students with disabilities and helps arrange the relevant accommodations.  If an officially  declared emergency makes travel to campus infeasible, USC Emergency Information provide safety and other updates, including ways in which instruction will be continued by means of blackboard, teleconferencing, and other technology.

Suggested Books and References:

Main Sources (Books, Agencies’ reports, & Articles)
Perrow, C. (2007). The Next Catastrophe: Reducing our Vulnerabilities to Natural, Industrial and Terrorist Disasters. Princeton, NJ: Princeton University Press.

Perrow, C. (1999) (2nd edition). Normal Accidents: Living with High-Risk Technologies. Princeton Paperback.

Perrow, C. (1986) (3rd Edition). Complex Organizations: A Critical Essay New York: Random House.

Pool, R. (1997). Beyond Engineering: How Society Shapes Technology. Oxford Paperbacks.

Reason, J. (2013). A Life in Error: From Little Slips to Big Disasters. Burlington, VT: Ashgate.

Reason, J. (2008). The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Burlington, VT: Ashgate.

Reason, J. (1997). Managing the risks of organizational accidents. Burlington, VT: Ashgate.

Reason, J. (1992). Human error. Burlington, VT: Ashgate.

National Academy of Engineering/National Research Council (NAE/NRC) (2011). Macondo Well Deepwater Horizon Blowout: Lessons for Improving Offshore Drilling Safety. The National Academies Press, Washington, D.C.

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (2011). Deep Water: The Gulf Oil Disaster and the Future of Offshore Drilling, Report to the President. Washington, DC: National Commission on the BP Deepwater Oil Spill and Offshore Drilling.

National Academy of Sciences (2014). Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants. NAS Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants, Washington D.C.: The National Academis Press.

National Transportation Safety Board NTSB (2014). Organizational Factors in Metro-North Railroad Accidents: Special Investigation Report. NTSB/SIR-14/04, PB2015-101211.

US Nuclear Regulatory Commission (NRC) (2011, Tuesday June 14). Final Safety Culture Policy Statement. Federal Register, Vol. 76, No. 114, 34773-34778.

US Nuclear Regulatory Commission (NRC) (April 2009). Internal Safety Culture Task Force (Final Report).

US Nuclear Regulatory Commission (NRC) (July 21, 2011). Recommendations for Enhancing Reactor Safety in the 21st Century: The Near-Term Task Force for Review of Insights from the Fukushima Dia-ichi Accident.

Weick, K. E., & Sutcliffe, K. M. (2007) (2nd edition). Managing the Unexpected: Resilent Perfomrance in an Age of Uncertainty . Jossey-Bass.

Wilpert, B. and Itoigawa, N. (Eds.) (2001). Safety Culture in Nuclear Power Operations. London: Taylor and Francis.
AcciMap-related Material
Rasmussen, J. (1997). Risk management in a dynamic society: A modeling problem. Safety Science, 27(2/3), 183-213.

Rasmussen, J. and Svedung, I. (2000). Proactive Risk Management in a Dynamic Society. Raddningsverket. Risk and Environmental Department. Swedish Rescue Services Agency, Karlstad, Sweden.

Svedung, I. and Rasmussen, J. (2002). Graphic representation of accident scenarios: Mapping system structure and the causation of accidents. Safety Science, 40, 397-417.

Branford, K. (2011). Seeing the big picture of mishaps: Applying the AcciMap approach to analyze system accidents. Avaiton Psychology and Applied Humma Factors, 1(1), 31-37.

Trotter, Margaret J., Paul M. Salmon, and Michael G. Lenne. Impromaps: Applying Rasmussen’s Risk Management Framework to improvisation incidents. Safety Science, 64, 60-70.
Supporting Material and Case Studies Sources
Acton, James M. and Hibbs, Mark (2012, March). Why Fukushima was Preventable. Carnegie Endowment for International Peace, the Carnegie Papers (Nuclear Policy), Washington, DC.

Clarke, L. (1999). Mission Impossible: Using Fantasy Documents to Tame Disaster. Chicago: The University of Chicago Press.

Cooke, N.J. and Durso, F. ( 2008). Modern Technology Failures and Cognitive Engineering Successes. New York: CRC Press, Taylor & Francis Group.

Department of Energy (2012, May 29). Accident and Operational Safety Analysis, Volume I: Accident Analysis Techniques. DOE Handbook, DOE-HDBK-1208-2012.

Department of Energy (2009, June). Human Performance Improvement Handbook, Volume 1: Concepts and Principles. DOE Standard, DOE-HDBK-1028-2009.

Department of Energy (2009, June). Human Performance Improvement Handbook, Volume 2: Human Performance Tools for Individual, Work Teams, and Management. DOE Standard, DOE-HDBK-1028-2009.

Disaster Resilience: A National Imperative (2012). Committee on Increasing National Resilience to Hazards and Disasters; Committee on Science, Engineering, and Public Policy; The National Academies.

Human-System Integration in the System Development Process: A New Look (2007). Committee on Human-System Design Support for Changing Technology, Richard W. Pew and Anne S. Mavor, Editors, Committee on Human Factors, National Research Council.

Gelfand, M.J., Frese, M. and Salmon, E. (2011). Cultural influence on errors: Preventions, Detections, and Management. In D.A. Hofmann and M. Frese (Eds.), Errors in Organizations. New York: Routledge, Taylor & Francis, 273-315.

Hollnagel, E. (Ed.) (2010). Safer Complex Industrial Environments: A Human Factors Approach. New York: CRC Press, Taylor & Francis Group.

Hollnagel, E. (2004). Barriers and Accident Prevention: How to Improve Safety by Understanding the Nature of Accidents rather than Finding their Causes. . Burlington, VT: Ashgate.

Hofmann, D.A. and Frese, M. (Eds.) (2011). Errors in Organizations. New York: Routledge, Taylor & Francis Group.

Kletz, T. A. (1988) (2nd Edition). What Went Wrong? Case Histories of Process Plant Disasters. Houston, TX: Gulf Publishing Company.

Institute of Nuclear Power Operations (INPO) (2012, August). Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station. INPO 11-005 Addendum.

Institute of Nuclear Power Operations (INPO) (2011, November). Special Report on the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station. INPO 11-005.

International Atomic Energy Agency (IAEA) (2012). Safety Culture in Pre-Operational Phases of Nuclear Power Projects. IAEA Safety Series No. 74.

International Atomic Energy Agency (IAEA) (2008). Nuclear Security Culture. IAEA Nuclear Security Series, No. 7.

International Atomic Energy Agency (IAEA) (2002). Safety Culture in Nuclear Installations: Guidance for use in the Enhancement of Safety Culture. IAEA-TECDOC-1329.

International Atomic Energy Agency (IAEA) (2005). Safety Culture in the Maintenance of Nuclear Power Plants. IAEA Safety Series No. 42.

International Atomic Energy Agency (IAEA) (1992). The Chernobyl Accident: Updating of INSAG-1 (INSAG-7), Vienna: IAEA.

International Atomic Energy Agency (IAEA) (1991). Safety Culture. IAEA Safety Series No. 75. A report by the International Nuclear Safety Advisory Group (INSAG).

Leveson, N. (2004). A New Accident Model for Engineering Safer Systems. Safety Science, 42(4): 237-270.

Leveson, N. (2011). Engineering a Safer World: Systems Thinking Applied to Safety. The MIT Press.

Le Coze, J.C. (2014). Reflecting on Jens Rasmussen’s Legacy; A Strong Program for a hard Problem. Safety Science,

Lochbaum, D., Lyman, E., Stranahan and the Union of Concerned Scientists (2014). Fukushima: The Story of a Nuclear Disaster. New York: The New Press.

Macfarlane, Allison (2012, Monday, September 17). Assessing Progress in Worldwide Nuclear Safety, Remarks of NRC Chairman Allison M. Macfarlane, International Nuclear Safety Group (INSAG) Forum, International Atomic Energy Agency (IAEA), Vienna, Austria.

Meshkati, N. (1991). Human Factors in Large-Scale Technological Systems' Accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis Quarterly, 5, 133-154.

Meshkati, N. (1995). Human factors in process plants and facility design. In R. Deshotles and R. Zimmerman (Eds.), Cost-Effective Risk Assessment for Process Design. New York: McGraw-Hill, 113-130.

Meshkati, N. (1999). Cultural context of nuclear safety culture: A conceptual model and field study. In J. Misumi, B. Wilpert, R. Miller (Eds.), Nuclear Safety: A Human Factors Perspective. London: Taylor and Francis, 61-75.

Meshkati, N. (2012). Engineering diplomacy: An underutilized too in foreign policy. Science & Diplomacy (“a quarterly publication from the American Association for the Advancement of Science (AAAS), the world’s largest general scientific society”) 20-30.

Meshkati, N. and Chin, A. (In review). A Safety Case tsunami from across Atlantic Ocean is coming towards US’s coasts, Professional Safety.

Meshkati, N. and Khashe, Y. (Accepted for publication). Operators’ improvisation in complex technological systems: Successfully tackling ambiguity, enhancing resiliency and the last resort to averting disaster. Journal of Contingencies and Crisis Management (JCCM).

Miang, Goh Yang, and Ting, Soon Wei (2014). Safety Management Lessons from Major Accident Inquires. Singapore: Pearson Education South Asia Ltd

Misumi, B., Wilpert, B. and R. Miller (Eds.) (1999) Nuclear Safety: A Human Factors Perspective. London: Taylor and Francis.

The National Diet of Japan (2012, July). The Official Report of the Fukushima Nuclear Accident Independent Investigation Commission. Published by The National Diet of Japan: The Fukushima Nuclear Accident Independent Investigation Commission.

National Transportation Safety Board (NTSB) (2011). Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire, San Bruno, California, September 9, 2010. PAR-11/01. Washington, DC: NTSB.

National Transportation Safety Board (NTSB) (2010). Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains New Fort Totten Station. Washington D.C., June 22, 2009, RAR-10/02. Washington, DC:NTSB.

Nuclear Energy Institute (June 2009). Fostering a Strong Nuclear Safety Culture (NEI 09-07).

Oedewald, P., Pietikäinen E., and Reiman, T. (2011) 2011:20 A Guidebook for Evaluating Organizations in the Nuclear Industry: an example of safety culture evaluation.

Phimister, J.R., Bier, V.M., and Kunreuther, H.C. (Eds.) (2004). Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence. National Academy of Engineering. Washington, D.C.: The National Academy Press.

Qureshi, Z.H. (2008). A Review of Accident Modeling Approaches for Complex Critical Sociotechnical Systems (DSTO-TR-2094). Australian Government, Department of Defense, Defense Science and Technology Organization

Report of Japanese Government to the IAEA Ministerial Conference on Nuclear Safety: The Accident at TEPCO's Fukushima Nuclear Power Stations (June 2011).

Sagan, D. S. (1993). The Limits of Safety: Organizations, Accidents, and Nuclear Weapons. Princeton, NY: Princeton University Press.

Schlosser, E. (2013). Command and Control: Nuclear Weapons, the Damascus Accident, and the Illusion of Safety. New York: The Penguin Press.

US Chemical Safety And Hazard Investigation Board (CSB). (2007). Refinery Explosion and Fire: BP Texas City, March 23, 2005. Investigation Report. Washington, DC: CSB.

US Chemical Safety and Hazard Investigation Board (CSB). (2013). Regulatory Report: Chevron Richmond Refniery Pipe Rupture and Fire. Washington, DC: CSB.

US Chemical Safety and Hazard Investigation Board (CSB). (2014). Investigation Report of Catastrophic Rupture of Heat Exchanger. Washington, DC: CSB.

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