Safety Science 48 (2010) 12861295

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/ssci

Development of socio-technical disaster model

M.S. Aini a,*, A. Fakhrul-Razi b
a
Department of Resource Management and Consumer Studies, Faculty of Human Ecology, Universiti Putra Malaysia, 43400 Selangor, Malaysia
b
Department of Chemical and Environmental Engineering, Faculty of Engineering, Universiti Putra Malaysia, 43400 Selangor, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: Using a grounded theory approach, six public inquiry reports were utilized to identify the phases associ-
Received 24 June 2008 ated with the development of socio-technical disasters. Despite the differences of disasters involved and
Received in revised form 8 March 2010 their technologies, the disasters were found to exhibit common features and characteristics. The ndings
Accepted 6 April 2010
demonstrated that socio-technical disasters are not sudden cataclysmic events but they evolved in
phases with long developmental period. A model of the sequential development of socio-technical disas-
ter is proposed as consisting of ten phases namely operation, incubation, forewarning, activation, onset,
Keywords:
rescue and recovery, inquiry and reporting, feedback, social justice, and social and legislation reform. This
Socio-technical disaster
Incubation
model reafrms and advances developmental theory of disasters.
Inquiry 2010 Elsevier Ltd. All rights reserved.
Rescue
Response

1. Introduction increasingly linked to human intervention. In addition, there has

Disasters are evolving rapidly in response to major changes on
our society and they mutate in form, in response to population
growth and urbanization, economic growth, globalization of com-
merce, technology advancement and other trends now underway
worldwide (Hooke, 2000; Picou et al., 2004). Disaster scholars
who investigated the relationship between development and vul-
nerabilities concluded that the impact of disasters is likely to in-
crease in the future. They are attributed to various reasons. We
develop modes of social organization and technology that can do
very large-scale damage, and we do that faster than we develop
techniques to control damage or respond to it effectively once
the inevitable disaster happens (Roush, 1993).
By and large, disasters can be classied into two broad catego-
ries that are natural and man-made. Man-made disasters which
are also referred to as socio-technological disasters involve a loss
of control over processes perceived to be controllable, whereas
natural disasters involve a lack of control over processes perceived
to be uncontrollable (Baum et al., 1983). Man-made disasters in-
volved identiable parties to blame and hold accountable (Gill
and Picou, 1998). However, recent development shows that the
boundary between natural and human causes and therefore be-
tween natural and man-made disaster is becoming vague
(Shrivastava, 1994; Wells et al., 2000; Weichselgartner, 2001). Nat-
ural disaster such as droughts, oods and desertication are
* Corresponding author. Tel.: +60 3 89467094; fax: +60 3 89436157.
E-mail addresses: ainims@putra.upm.edu.my (M.S. Aini), fakhrul@eng.upm.
edu.my (A. Fakhrul-Razi).
been a paradigm shift in conceiving disasters as act of God to so-
cio-technical phenomena stemming from compound interaction
of physical, built, technological and social system (McEntire,
1997). Thus the responsibility for causing disasters are ascribed
to industry or government, and to the latter for not enforcing reg-
ulations, anticipating disasters, or responding in a manner ex-
pected by victims (Picou et al., 2004).
Disaster research has attracted specialists with a wide variety of
professional backgrounds such as medical, psychologists, geologist,
engineers, management and social scientists undertaking disaster
studies. Each discipline has made its own important contribution
to the understanding of the origin of disasters, expansion of emer-
gency and disaster preparedness to encompass planning and miti-
gation, in addition to response and rehabilitation.
Many areas of academic elds too have evolved such as safety
culture, hazard and risk management, crisis management, emer-
gency response and planning etc.
Besides negative impacts of disaster on lives and properties of a
society, lessons from them had also led to the development of
important safety laws and regulations and establishment of spe-
cialized functional organizations and bodies. Even more signicant
during these decades have been the changes in attitude regarding
the inevitability of disasters (Toft and Reynolds, 1994), from fatal-
istic resignation to intervention by specialized disaster agencies
aiming at gaining human control over fate (Granot, 1998). It was
shown that vast majority of the accidents could have been foreseen
early and consequently prevented by the proper application of
existing experience and dissemination of learning from past inci-
dents (Drogaris, 1993). The hindsight gained from these events

0925-7535/$ - see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2010.04.007
 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295
could be utilized by government and enterprises to design organi-
zational structures, which will help reduce accidents as a nation
progresses.
Princes research on the Halifax shipwreck and resulting mas-
sive explosion of trinitrotoluene (TNT) in 1920 is the rst social sci-
ence study of disasters. This study and other earlier studies of
disasters take the onset of the disasters as the starting point for
their research, response to the catastrophe and preoccupied with
prompt return to normalcy (Blockley, 1998; Rosenthal, 1998;
Turner, 1976). They also tended to concentrate upon accumulation
of experience within industrial sectors rather than looking across
them, due to the prevalence belief that all disasters are different
(Turner and Pidgeon, 1997). Learning from across events and sec-
tors are relevant and signicant because disastrous events within
sector and in the same industry are low and infrequent. Thus due
to the narrow analysis of particular case, it has therefore been lack-
ing in theoretical investigations on causes, origin, foundation and
concepts of disasters (Gilbert, 1998).
Turner is among the rst to study disasters that conceived them
in terms of process rather than as a sudden act of God and exam-
ined man-made disasters across various sectors and anchored his
study from pre-disaster phase. His ndings had led to the under-
standing of the sequence of development of disasters showing that
they are not sudden cataclysmic events but develop in stages with
long gestation period. Turner was also among the rst to show that
disasters are a socio-technical problem, hence the term is used by
some scholars to refer to man-made disasters. They were found to
be caused by failures in technical, social, institutional and admin-
istrative arrangements in combination systematically producing
the disasters (Bowonder et al., 1985; Shrivastava et al., 1988;
Turner, 1994; Ibrahim et al., 2003).
A major contribution that Turner (1976) made was to use
grounded theory to identify emergent properties, and the identi-
cation of incubation period where there is a pre-condition to fail-
ures (Blockley, 1998). As cited by Blockley (1998), Pugsley (1969)
had identied a similar concept to pre-conditions to failure, which
he termed it proneness to failure. This concept has been employed
by engineers for technical reliability and risk calculation.
Shrivastava was among the rst to analyze disaster events that
occurred in different nations. He illustrated the presence of devel-
opmental phases of disasters through case studies of the Bhopal
disaster of 1984, Tylenol poisonings in Chicago on 29 September
1982, and the Shuttle Challenger disaster on 28 January 1986.
His research has led to the development of Industrial Crises Model
where crises were found to evolve in four phases namely pre-crisis
conditions, triggering event, crisis extensions and the nal phase is
crises resolution or post crisis normalization (Shrivastava et al.,
1988).
There are several other disaster studies that reafrm and extend
the developmental stages of disaster. For example, Fink (1986) sug-
gested four phases of disaster: pre-incident or prodromal crisis
warning stage of an impending crisis; the incident itself acute
crisis; chronic crisis post incident phase of recovery or clean-
up; and crisis resolution- the goal of the previous three stages,
recovery of the enterprise.
Toft and Reynolds (1999) had further extended Turners se-
quence model. A systems failure and cultural readjustment model
(SFCRM) consisting of seven stages was proposed. Ibrahim et al.
(2002) had recently utilized Turners sequential model to examine
the failures of major hazard installations in Malaysia. Using case
study approach of seven industrial disasters, they proposed an
IbrahimRazis Model of technological man-made disaster pre-
condition phase model. The study has also identied that the
length of incubation period where there is an accumulation of
embedded failures and errors varied among the disasters, ranging
from three to 30 years. The pre-disaster period was envisaged to
1287
be consisting of eight phases. The above literature demonstrates
that man-made disasters are not sudden cataclysmic events but
had long gestation period. They exhibited various phases within
three distinct periods of pre-disaster, disaster and post-disaster.
2. Methods
2.1. Research design
The study adopted a qualitative research strategy utilizing a
case study method. Qualitative research is a research strategy that
emphasized words rather than quantication in the data collection
and data analysis (Bryman, 2001). Since the researcher is inter-
ested in the insight, discovery, and interpretation (generation of
theories) rather than hypothesis testing (theory testing), qualita-
tive methods of data collection and data analysis were best suited
for this purpose (Cronbach, 1975; Merriam, 1988; Silverman,
1993). A qualitative case study design entails an examination of
one setting, or one single subject, or one single depository of doc-
uments, or one particular event (Bogdan and Biklen, 1982). Case
study is an empirical inquiry that focuses on in-depth understand-
ing of a phenomena and its context (Cavaye, 1996). Case study
analysis is holistic and systemic as it is seeing the whole and
the various sub-wholes within a case. The connection between
the parts is as important as the presence of the parts themselves
if failure is to be avoided and safety is to be assured (Bignell,
1999). Quantitative study utilizing statistical analysis may reveal
a succession of cause-effect relationships, but they fail to reveal
the processes underlying the relationships. Thus, the answer to
understand safety or disaster question lie not in numbers, but in
the interpretation of the processes behind the numbers (Maurino,
2000).
Case study approach had been utilized by many researchers in
understanding development of disasters. Turner had analyzed in-
quiry reports of 84 selected accidents that were published by the
British Government during the years 19651975. Toft and
Reynolds (1999) had used case studies of 19 selected disasters
and data was analyzed using grounded theory approach. Normal
Accident Theory proposed by Perrow (1984) had emerged from
an analysis of the accident at the Three Mile Island nuclear power
plant in Pennsylvania in 1979. Shrivastava et al. (1988) had ana-
lyzed three case studies and proposed a conceptual framework
for understanding of industrial crises.
The present study aims to identify the phases associated with
the development of the socio-technical disasters. Multiple-case de-
sign was adopted in this study instead of single case in order to lit-
eral/theoretical replication and cross-case comparison (Darke
et al., 1998). Two main issues that may limit the validity of quali-
tative study in general and case study in particular are data collec-
tion and data analysis processes as they depend on the
perspectives and skill of the researcher (Sofaer, 1999; Darke
et al., 1998). The cases chosen in the study were purposely selected
rather than randomly to meet the theoretical needs of the study.
The data for the study were ofcial documents of the Malaysian
Government on the reports of public inquiries into on-land man-
made disasters. There were six such disasters recorded up to date
and all were selected for the study. Due to the nature of public in-
quiry, its reports into disasters are more independent and objective
as compared to internal investigations made within organizations.
Public inquiry into disasters has statutory power to compel pro-
duction of documents and call for witnesses. The process of public
inquiry is open to public, hearing conducted in public, documents
and reports are accessible to public and those affected can be rep-
resented by counsels (Commissions of Enquiry Act 1950). The use
of public inquiry reports would ensure that the data is authentic
1288 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295

and credible as quality of documents can be ascertained by these Table 1

two criteria (Bryman, 2001). Lists of inquiry reports.

Minimization of the investigator-dependent nature of the study Title of Document Royal Public
during data analysis was made by developing a data analysis strat- Inquiry Inquiry
egy as part of the study design. Analysis of qualitative data in the Report Report

study utilized constant comparative method, which was developed 1 Report of the Royal Commission of the Enquiry U
by Glaser and Strauss (1967). A le folder method was used as a to Investigate Into The Causes of the Collapse of
a Four-Story Building on Lot No. 503 Jalan Raja
strategy for organizing the data in preparation for analysis. Before Laut, Kuala Lumpur on 19th October 1968
the codes or categories were developed, several considerations Volume I and II
were given as suggested by Loftland and Loftland (1995). Guide- 2 Report of the Royal Commission into the U
lines provided by Merriam (1988) had been used to determine Collapse of Part of the Platform of the
the efcacy of categories (concepts or themes indicated by the Passenger Waiting Area of the Sultan Abdul
data). These measures were undertaken to ensure that the research Halim Ferry Terminal at Butterworth on 31 July
1988
undertaken is systematic, rigorous and well-designed as it seeks to
reduce bias and error. 3 Report of The Royal Commission To Enquire U
Into The Fire at Tauqiah Khairiah Al-Halimiah
Religious School, Padang Lumat, Yan Kedah on
2.2. Data collection 22 September 1989
Volume 1
The disasters that were included in the study were socio-tech- 4 Report of The Royal Commission To Enquire U
nical, on-land disasters that fall under the ambit of the Malaysian Into The Safety of Private Schools and Religious
National Security Council Directive No. 20. It is the Policy and Schools in West Malaysia.
Mechanism of Disaster Management and Relief of Malaysia for Volume II

on-land man-made disasters. Thus natural, aviation and marine
disasters were excluded in the study. The disasters included had
led to the call for either a Public Inquiry or Royal Public Inquiry.
A Royal Public Inquiry following a disaster is a special type of dis-
cretionary inquiry set up under the Commissions of Enquiry Act
1950. It needs the authorization of parliament and the King is
vested with the power to issue a commission appointing one or
more Commissioners. Public inquiry following a disaster may be
ordered on a statutory basis under legislations for example, under
the Occupational Safety and Health Act 1994.
Inquiry reports are considered primary sources because they
are recorded closest in time to the phenomena and they contained
eyewitness accounts (Merriam, 1988). They are authentic docu-
ments since they were ofcial reports of the inquiry into the disas-
ters. Although they have shortcomings and weaknesses, it is
important that they are fully exploited to draw out the lessons of
disaster causation and prevention as they will remain as the valu-
able source of information to understand the development of
disasters and help prevent recurrence of disasters (Toft and
Reynolds, 1999). The use of ofcial documents has been employed
by Turner (1994) where he utilized reports of public inquiries into
three disasters in order to study their pre-conditions. Toft and
Reynolds (1999) had used multiple data sources including that
from face-to-face interviews, letter correspondence, and published
and unpublished reports. Weick (1990) in his study of the Tenerife
plane crash in 1977 had used an ofcial report of the Spanish
Ministry of Transport and Communication and a report by the
US-based Airline Pilots Association.
The reports of the disaster inquiries used in this study were ob-
tained through various means for they were not located in a single
place. They were not easily accessible although they were sup-
posed to be public records. Various individuals who were high-
ranking government ofcers have helped the researcher in getting
hold of the inquiry reports. All the reports were then photocopied.
The reports of Royal and Public Inquiries in the socio-technical
disasters in Malaysia that were used for case study analysis are
listed in Table 1.
Other secondary documents such as inquiry reports of disasters
from other countries (e.g. United Kingdom, Australia and the
United States), newspaper cuttings, scholarly papers, books, ofcial
websites, etc. were also used in order to provide a comprehensive
perspective on some of the issues. They were also acquired from
face-to-face interview and correspondence via telephone and e-
mail. At the initial stage of the study, a face-to-face interview
5 Report of The Royal Commission To Enquire U
Into The Fire and Explosions at the Bright
Sparklers Sdn. Bhd. Factory at kampong Baru
Sungai Buloh Selangor Darul Ehsan on 7th May
1991
6 Report of The Inquiry Committee into Fire and U
Explosions at Port Kelang on 20 June 1992
7 Report of The Inquiry Committee Into The U
Collapse of Block 1 and the Stability of Blocks 2
and 3 Highland Towers Condominium, Hulu
Klang Selangor Darul Ehsan
8 Report of the Technical Committee of U
Investigation on The Collapse of Block 1 and
the Stability of Blocks 2 and 3 Highland Towers
Condominium, Hulu Klang Selangor Darul
Ehsan
Volume 3: Investigation Report of
Superstructure and Materials
9 Report of the Technical Committee of U
Investigation on The Collapse of Block 1 and
the Stability of Blocks 2 and 3 Highland Towers
Condominium, Hulu Klang Selangor Darul
Ehsan
Volume 5: Verbatim of the Interviews
10 Report of the Technical Committee of U
Investigation on The Collapse of Block 1 and
the Stability of Blocks 2 and 3 Highland Towers
Condominium, Hulu Klang Selangor Darul
Ehsan
Volume 6: Photographs of Site Investigation
Works and Laboratory Tests
was conducted with one of the commissioners for the Bright Spar-
klers disaster. The purpose was to solicit clarication and explana-
tion on some of the issues related to the conduct of Royal inquiry
into disasters. Another interview was conducted with a member
of the Public inquiry committee member for the Highland Towers
disaster. The purpose was to solicit his account of the experience
and his perception on some issues related to post-disaster phase.
The information obtained is not related to the content of the report
or on the disaster per say but about the process and procedures of
the public inquiry itself. The above steps were undertaken in order
to prepare the researcher with sufcient background about the
cases under study and to conrm the credibility of the inquiry
reports.
 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295
2.3. Data analysis
Two main approaches of qualitative data analysis are analytic
induction and grounded theory. Analytic induction is an approach
to the analysis of data in which the researcher seeks universal
explanations of phenomena by pursuing the collection of data until
no cases that are inconsistent with a hypothetical explanation of a
phenomenon are found. However, grounded theory has become by
far the most widely used framework for analyzing qualitative data
(Bryman, 2001). Thus, it was decided that the most appropriate
method of analysis for the collected qualitative data in this study
was grounded theory. Grounded theory approach was utilized by
Turner (1978) and Toft and Reynolds (1999) in analyzing the disas-
ter reports. Concepts and observations that are inductively arrived
at from the data are termed grounded theory by Strauss and Corbin
(1994). Analysis of qualitative data in the study utilized constant
comparative method, which was advanced by Merriam (1988).
The basic strategy of the constant comparative method is to make
comparisons constantly within and between levels of conceptuali-
zation until a theory can be formulated. Data are being organized
and managed by developing codes in which some form of designa-
tions to various aspects of the data are made. Thus coding of qual-
itative data represents an operation by which data are broken
down and conceptualized.
Background on each of the cases under study is briey
described below:
(i) Collapse of a Four-Story Building in Kuala Lumpur on 19
October 1968:
Before the Second World War, there were comparatively very
few buildings in the private sectors. The buildings that were
around were of simple structures, small houses and shop lots
and were designed on traditional lines. After independence in
1957, the country developed rapidly and resulted in the construc-
tion of large modern buildings. The collapsed four-story shop
house was one of the earliest high rise buildings to be built in
the capital city of Malaysia. The building which was nearing com-
pletion collapsed at about 3.15 p.m. on 19 October 1968, causing
the death of seven persons and injured 11 others. This was the rst
disaster of its kind that had happened in the country resulting in
the loss of lives and injury to several people. Following the disaster,
a Royal Inquiry was held under the provisions of the Commissions
of Enquiry Act 1950. There were three terms of reference of the
Commission: to investigate the causes for the collapse of the build-
ing; to make recommendations on the course of action to be taken
against those responsible, if any; and to make recommendations
on measures to prevent a recurrence of such accidents.
(ii) Collapse of part of the platform of the passenger waiting area
of the Sultan Abdul Halim Ferry Terminal in Butterworth on
31 July 1988:
The state of Penang is made up of an island and a strip of land
on Peninsular Malaysia. Travellers could either use the road or fer-
ry to go across to the Penang Island. With the post-war increase in
trafc (vehicular and passengers), double decker ferries were used
where the upper deck accommodates the foot passengers and the
lower deck for the vehicular trafc. The jetty situated on the main-
land is called Pengkalan Sultan Abdul Halim (PSAH). It was con-
structed in mid 1957 and started operation in September 1959.
On 31 July 1988, part of the upper deck of PSAH at Butterworth col-
lapsed causing 32 persons dead and an estimated number of 1543
people injured. This upper deck was used exclusively for the
embarkation and disembarkation of foot passengers using the ferry
service plying between Butterworth and Penang. In that collapse, a
1289
large part of the upper deck and the waiting passengers fell to the
lower deck and on the motorist and motorcyclists waiting for
embarkation. Arising from the disaster, the King appointed a com-
mission to inquiry into the collapse under Commissions of Enquiry
Act 1950. The terms of reference were: to investigate into, and
study the circumstances of the collapse of the relevant part of
the platform of the passenger waiting area of the Sultan Abdul
Halim Ferry Terminal at Butterworth in order to ascertain the
causes of such collapse; to determine whether or not there had
been any negligence or defect in the construction, maintenance
or control relating to the use, of that part of the said structure;
and to recommend to the Government the steps and measures that
should be undertaken to avoid the recurrence of similar incidents.
(iii) Fire at Tauqiah Khairiah Al-Halimiah Religious School in
Kedah on 22 September 1989:
Tauqiah Khairiah Al-Halimiah Religious School is one of the
oldest and was at that time the biggest private Islamic school in
Malaysia. The school has developed at an unprecedented rate since
its inception in 1941. In 1989, there was a total enrolment of 3273
students from all over Malaysia with 98 teachers. According to the
investigation by the commission, the re started at around two
oclock in the morning, at the lower level of Block E of the girls
hostel. The re had destroyed eight hostel buildings, caused 27
deaths and six injuries to female students. Arising from the disas-
ter, an inquiry was held under the Commissions of Enquiry Act
1950. There were three terms of reference of the commission: to
investigate into, and study the circumstances of the re in order
to ascertain the causes of the re; to investigate and study the
safety aspect of all private religious and private schools and their
hostels in order to determine whether the schools and the hostels
are safe for use in all aspects including safety procedures, re ght-
ing equipment, adequacy of the laws that govern the construction
and utilization of school buildings and hostels, and whether the
laws were abided; and to recommend to the Government the steps
and measures that should be undertaken to govern the construc-
tion and utilization of schools and hostels and with regards to re
prevention, re ghting, life and property protection in case of re.
(iv) The Fire and Explosions at Bright Sparklers Sdn. Bhd. Factory
on 7th May 1991:
Bright Sparklers Sdn. Bhd started its initial operations in 1974
and commenced commercial production of sparklers on 1 April
1975. At the time of the disaster, it employed 200 workers and
there were 43 buildings which were built very close to each other.
On 7 May 1991, at approximately 3.45 p.m., a re and several
explosions erupted at the reworks factory. All the structures
within the factory had been completely destroyed by the re and
explosions with the exception of two buildings where portions of
the cement walls and zinc roof remained intact. Debris, stones,
pieces of zinc roofs was hurled over one kilometer radius. The re
was believed to be initiated by a testing of a fountain just outside
the canteen by a pyrotechnics. The fountain exploded and the
smoldering fragments of the casing paper ew in all directions
and ignited the chemicals which were dried nearby. A total of 22
persons lost their lives with 75 employees and 28 non-employees
sustained injuries. Over 500 residential homes and eight other fac-
tories nearby were damaged as a result of the incident. Arising
from the disaster, the King appointed a commission to inquiry into
the re and explosions under the Commissions of Enquiry Act
1950. The terms of reference of the commission were: to investi-
gate and study the circumstances of the re and explosion which
caused the deaths of a number of persons and the destruction of
the Bright Sparklers Sdn. Bhd. factory in order to ascertain the
1290 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295

cause of the re and the explosion and those responsible therefore; to prevent future recurrences of such accidents; and to make an
to investigate and determine whether there has been any negli- assessment and recommendations on the fate of Blocks 2 and 3.
gence or failure to comply with all the relevant laws and regula-
tions on the part of any authorities or persons with regard to the 3. Findings
location, construction, maintenance and operation of the said fac-
tory; and to recommend steps and measures that should be taken Data indicated that the disaster cycle could be distinctly divided
with regard to the location, construction, maintenance and opera- into three periods namely pre-disaster, disaster and post-disaster.
tions of factories dealing with explosive and inammable materials Each of the periods was found to be consisted of several phases and
in Malaysia with a view to avoid the recurrence of similar inci- is discussed below.
dents. With regards to the third term of reference, it was not pur-
sued by the commission as the Government made a policy decision 3.1. Pre-disaster period
not to allow reworks factories to be established in the country on
12 August 1992. This policy was made after a re and deaths oc- 3.1.1. Operation phase
curred at another reworks factory on 22 July 1992 and resulted Operation phase is the Initial starting point where the socio-
in the closure of the factory by the relevant authorities. technical system begins its operation. This typically begins with
the formation or establishment, of corporations, institution, or edi-
(v) The Fire and Explosions at Port Kelang on 20th Jun 1992: ce (construction). In the six disasters that were studied, this phase
begins with either the incorporation of companies, registration of
Port Kelang is one of the main ports in the country. Fire and institution or preliminary phase of construction, which is conver-
explosion at Port Kelang was initiated by a re on board a ship/tan- sion of land.
ker docking at the jetty of Tiram Kimia Sendirian Berhad (TKSB).
The tanker, Choon Hong III was assigned to unload 400 metric tons 3.1.2. Incubation phase
of xylene for TKSB and Exxon Chemical (M) Sdn. Bhd. Due to the Subsequently, some time after the operation, digressions, devi-
damaged starboard pump, the port pump and the same cargo line ations and malpractices started to occur. These underlying errors
that was used to unload toluene was used to unload xylene. The incubated in the system until the triggering events set off the
triggering events to the disaster were due to the subsequent ac- disaster. The length of incubation phase and its percentage to the
tions that were undertaken to ush out contaminated xylene from total period of operation is as shown in Table 2.
the cargo line. There were at least ve explosions occurred on From the data, it was found that the length of the incubation
board the tanker. The areas that were affected by the re were: period of the disasters studied varies from one year to nineteen
parts of the Tiram Kimia Sendirian Berhad (TKSB) jetty; the tank years. The percentage of incubation phase to total period of opera-
farm of TKSB; storage area of drums of ammable materials of tion ranges from 14 percent to as high as 94 percent. Similar nd-
TKSB; re shed of TKSB where storage of re ghting equipment ings were found by Turner (1976) where the length of incubation
were kept; some parts of TKSBs ofce and production area and time varied from less than one month to 80 years for the 13 disas-
part of Royal Yacht Club. It caused death to 13 people. The cabinet ter reports analyzed. In a study conducted by Ibrahim et al. (2002)
called call for a Public Inquiry into the disaster under the provision on seven industrial disasters in Malaysia, they also identied that
of Section 45 of Fire Services Act 1988. The responsibilities and du- the length of incubation period varied among disasters, ranging
ties of the board of inquiry were: to investigate and examine the from three to 30 years.
circumstances of the explosion and re; to investigate the causes
and circumstances of the re and the re ghting and rescue ef-
3.1.3. Forewarning phase
forts and to report the causes, circumstances, and response; and
Within this incubation period, it was observed that a number of
to recommend based on the ndings of the inquiry, steps that
forewarnings happened to signal that something was not right and
can be undertaken to prevent similar incidents, and to improve re
ghting and rescue in general.
Table 2
(vi) The Collapse of Block 1 and the Stability of Blocks 2 and 3 of Percentage of incubation phase to total period of operation.
Highland Towers Condominium, Hulu Kelang on 11 Decem- Disaster Start of Total Length of Percentage of
ber 1993: operation period of incubation incubation
operation phase phase to total
Highland Towers, as was collectively known, consisted of three (years) (years) period of
operation (%)
blocks of 14 story buildings located at Hulu Kelang, Selangor. It was
gazette under the local authority of Majlis Ampang Jaya (MPAJ). On Four-Story Building 1963 5 1 20
collapse Kuala
Saturday, 11 December 1993 at approximately 1.30 p.m., Block 1 of Lumpur, 19 October
the Highland Towers Condominium suddenly toppled over and 1968
collapsed, after 10 days of continuous rainfall. The disaster had Collapse of Ferry 1959 29 4 14
caused 48 people dead. Arising from the disaster, MPAJ formed Terminal 31 July
1988
an inquiry committee, headed by the Director General to investi-
Fire at Religious School 1942 47 16 43
gate into the collapse of the tower. This was set up pursuant to Sec- Tauqiah 22
tion 258 of Uniform Building by Law 1984. The inquiry committee September 1989
consisted of a main inquiry committee and three technical sub- Fire and Explosions of 1973 18 17 94
committees. The members of the main committee consisted of Bright Sparklers 7
May 1991
20 people representing various government departments and pri-
Fire and Explosion at 1978 14 11 79
vate organizations. The terms of reference of the Committee of In- Port Kelang 20 June
quiry were: to investigate into the causes of the collapse of Block 1 1992
and to identify the party or parties responsible for the collapse; to Collapse of Highland 1964 29 19 66
Towers 11
make recommendations on actions that could be taken against
December 1993
those responsible, if any; to make recommendations on measures
 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295 1291

unacceptable. Table 3 provides illustrations of incidences that rep-
resented early warnings. Thus, ample signs and warnings were dis-
played which indicated that the state of affairs and circumstances
pointed to safety problems. However these were ignored, disre-
garded or misinterpreted by the organization. If proper appraisal
of the situation was made and appropriate remedial actions were
taken, the disasters could be avoided. Studies by Turner and
Pidgeon (1997) revealed similar patterns where danger signs were
visible by individuals and groups regarding the expected failure,
but they had not been taken into account by appropriate organiza-
tion or authority. Other major disasters such as Bhopal experienced
six accidents prior to the disaster event (Bowonder et al., 1985).
3.1.4. Activation phase
The immediate cause that activates or triggers the disasters is
traceable to individuals or specic event such as: the building
which was nearing completion suddenly collapse; overloading
and unruly behaviour of the passengers caused the upper deck of
jetty to collapse; candle re used by a student to study late at night
caught a mattress on re; testing of a new rework by the pyro-
technic near the canteen, smouldering fragments ignited chemicals
which were being dried nearby; spark produced during the lling
up of contaminated uid from the cargo line into tank and ignited
the highly ammable xylene that was aboard the tanker; and hea-
vy rain had caused landslide and had toppled the retaining wall
and caused Block 1 to topple over. Without proper investigation
and inquiry being carried out into the disasters, the blame of the
disaster will be placed on them. In these circumstances, the under-
lying causes will lay buried underneath.
3.2. Disaster period
3.2.1. Onset
The onset of the disasters started after being activated by the
triggering events, which may be due to unsafe act or unsafe condi-
tion as illustrated above.
3.2.2. Response and recovery phase
The steps in active response of the emergency services include
immediate detection and characterization of the disaster, preven-
tive actions were taken to prevent escalation and containment of
the impact, neutralization and nally recovery plan was initiated.
These steps of active response are well recognized (Ren, 2000)
and its effectiveness has helped in preventing loss of life, minimiz-
ing the destruction of properties and recovery of the affected com-
munity to normalcy. The immediate response is very important as
it is the last set of defence an organization possesses against disas-
ters (Reason, 1997). However, data showed that in some of the
disasters studied, the immediate response from those at the vicin-
ity of the incident was very poor. In all the disasters studied, the
response to the call of emergency by the Fire and Rescue Services
was very swift and prompt. However the response and rescue ef-
forts were often hindered by a number of factors such as lack of
proper equipment, absence of re hydrants, ill-trained to response

Table 3
Forewarning incidences of socio-technical disaster.

Disaster
Four-Story Building collapse Kuala
Lumpur, 19 October 1968
Collapse of Ferry Terminal 31 July 1988
Fire at Religious School Tauqiah 22
September 1989
Fire and Explosion at Bright Sparklers 7
May 1991
Fire and Explosion at Port Kelang 20 June
1992
Collapse of Highland Towers 11 December
1993
Forewarnings
h Hairline cracks were noticed by the cement head on the ground oor beams adjoining column 6/a. Remedial action was
taken by placing a large concrete block between the ground beams and the footing of column 6/a. This action had
increased the load on the footing thereby aggravating the situation, which it was supposed to alleviate.
h Another defect was found in column 6/a during the construction period where it had settled into the ground by 2 in.
The construction of the remaining oor was continued and no measurement was further taken. However the column
was found to sink further after the building was completed. The contractor, the architect or Wong Kah Kin & Co. took
no remedial action.
h These were two occasions, which indicated that all was not well with the reinforced concrete structure. Yuen, the
architect failed to advice the company to obtain the services of a consulting engineer.
h By noon on 31 July 1988, the ferry manager had realized that the passengers were getting heavy but no effective strat-
egy was taken to stop them from getting into the jetty and in particular into the waiting area on the upper deck.
h A circular dated 20 February 1989 was sent to Chief secretary of Ministry of Housing and Local Government and Min-
istry of education, all State Fire Chiefs and all directors of State Education Department, highlighting the re incident at
Sri Inai Secondary School hostel on 16 February 1989 and the necessary measures to be undertaken in order to ensure
safety of students in school hostels.
h A second circular was sent by the Fire Services department to all local authorities where a comprehensive guideline on
re prevention and safety procedures was attached. Appropriate actions were expected to be undertaken by respective
local authorities in ensuring that these guidelines are followed.
h Due to physical and psychological stress of the students, cases of hysteria were reported a few times before the
disaster.
h Due to heavy subject loading, students were regularly found to stay up late at night to study using candlelight. No
proper study facilities were available after class hours.
h Although there were six re accidents prior to the disaster in 1991, which had resulted in death and property, damages,
BS did not take any lessons from them.
h Although police reports were lodged, Chemistry Department and Fire Services Department carried out the investiga-
tions, there was no positive actions taken by the authority.
h The cargo line could not be cleaned from toluene even after ushing out 15 drums of xylene through it. This should
make them stop from using the cargo line and nd alternative arrangement.
h The method of transferring the contaminated uid into the drums was inappropriate as an accident occurred where a
worker was splashed with the uid. After running out of drums for storage, the contaminated uid was to be channeled
into tank 3S, which do not have dropping line facility. A lot of mists and adjustments were made without making risk
assessment of the situation.
h Flooding of Highland Towers ground on 9 November 1978. No drain reserve provided as required by JPT.
h On 18 April 1979, ooding and silting in the neighboring houses.
h Denudation of the land by removing slope vegetation and trees had occurred and recorded by the authority since 1985.
h In 1992, mudow and siltation onto Highland Towers ground were experienced during and after rainfall due to con-
struction activities.
h Some months before the disaster, there was ooding of the car parks at HT with rock and mudslide.
1292 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295
appropriately and poor co-ordination among response agencies.
The examples above demonstrated that the accident escalated to
disasters due to ineffective measures and actions or inaction by
organizations involved and that of response agencies during the
initial phase of the onset of the event. Lessons from the response
phase are important in preventing loss of life, minimizing the
destruction of properties and environment.
3.3. Post-disaster period
This period is the time after search and rescue operations is
over. The length of this period is indeterminate as social justice, so-
cial and legislations reforms may take a long time after the disaster
occurred. Bhopal, Chernobyl, Aberfan and many other socio-tech-
nical disasters show lack of discrete endings and it is the end of
normalcy to the victims (Freudenburg, 1997).
3.3.1. Inquiry and reporting
Essentially there are three options to opt for with regards to the
type of inquiry following an incident: technical investigation; pub-
lic inquiry; Royal inquiry or Presidential Commission. The right to
conduct an investigation ensuing an accident is provided by vari-
ous provisions in numerous acts and regulations. Many statutes
provide mandatory inquiries and give the discretion for a more for-
mal investigation, which is generally termed as public inquiry. An-
other special type of discretionary inquiry is the Royal Inquiry.
These two forms of inquiry are set up to investigate into the causes
of major accidents/ disasters, which caused massive loss of life and
property damage. However the conditions and terms were spelt
out in general and it is up to the authority or Government to make
a nal decision as to which type is appropriate. This leaves a signif-
icant discretion in the hands of the Government in how to orches-
trate the response to a disaster (Wells, 1999). Of the six disasters
studied, four of them had resulted in Royal inquiry while two were
of Public inquiry. The ndings showed that the choice of the type of
inquiry to investigate into disasters in the country is very much
subjected to interpretation and judgment of those in power. Public
pressure particularly from professional bodies can at times per-
suade and inuence the decision of the Government such as that
of the Four-Story Building collapse in Kuala Lumpur. In the United
Kingdom, pressure from victims, public and media has led to the
reinvestigation of the Marchioness passenger vessel disaster from
technical inquiry to a Public inquiry (Clarke, 2000). It was recom-
mended because of inadequate and appalling investigation and re-
port by the previous investigation committee. This serves to
illustrate that different types of inquiry into a disaster may result
in different ndings and conclusions. This situation substantiate
ndings by Wells (1999) that shows how lack of uniformity and
guidelines can lead to signicant discretion of the Government in
how to orchestrate a response to a disaster. Thus determination
of an appropriate type of inquiry into an accident has great
consequences.
3.3.2. Feedback
Feedback involves the recipient and implementation of the rec-
ommendations from the inquiry by the organization concerned
and by organizations exposed to the same or similar risk. All the in-
quiry reports that were studied had recommendations made by the
inquiry committee except for the case of Bright Sparklers due to
the forsaken of the third terms of reference by the Government.
However some initial recommendations particularly to the estab-
lishment that is directly involved may be fed back before the main
inquiry has nished its deliberations. It may also occur voluntarily
by concerned organizations. It appears that as soon as the news of
the disaster incident proliferated in the society through the mass
media, those who sensed that they have some accountability over
the incident tried to take some immediate measures to improve
their administrative or technical aspects.
With regards to the recommendations made by the Commission
directed at the Government and public agencies, their level and
rate of implementation are not- satisfactory. One of the main rea-
sons is due to absent of power by the Commission to ensure that
individuals, public bodies, or private organizations to implement
their recommendations. The commissioners of the public inquiries
in United Kingdom too have no power to do so as well and it be-
come a device employed by governments to pacify the public (Toft
and Reynolds, 1999).
3.3.3. Social justice
The ndings and reports of the inquiries are able to assist rele-
vant organs of the government, organizations or victims to take
further actions under prevailing laws, rules and regulations against
those identied responsible by the inquiry committee. From the
analysis of the six disaster reports, it shows that the commission
is sometimes explicit and sometimes implicit in reporting those
responsible for the disaster. The nature of the inquiry is inquisito-
rial rather than adversarial, thus it is not the duty of the commis-
sion to determine any criminal responsibility or civil liability of
those responsible to the incident. Appropriately, the commission
recommended that claims of damages for negligence by way of ci-
vil actions are up to the legal representatives of those affected by
the disaster. Any ground for criminal negligence on the part of
any or all of those responsible for the collapse is up to the Attorney
General to consider to direct further investigations and /or to legal
action.
The ndings above showed that it was possible for those af-
fected by the disaster to take civil actions against those responsible
for the disaster. The Attorney General can investigate further any
criminal negligence or to press charges against them. However,
some members of the public particularly among the lower social
economic accept these incidents as fate and do not blame any party
for it or are ignorant of legal proceedings. Consequently, legal ac-
tions are not pursued. Victims and relatives of the victims of two
disasters, Bright Sparklers and Highland Towers tragedy, led law-
suits but the court case for both disasters above are not resolved
yet although the incidents happened over ten years ago. Thus the
litigation process becomes a source of chronic psychological stress
to the victims. Studies have shown that the legal system itself can
become a secondary disaster, exacerbating and prolonging psycho-
logical stress and perceived community damage (Picou et al.,
2004). The protracted litigation process is exemplied in cases
such as that of Exxon Valdez and Bhopal.
With changing paradigm where disasters are viewed as stem-
ming from anthropogenic forces, with responsibility ascribed to
industry or government for causing disasters, corporate man-
slaughter prosecutions have been on the rise particularly in devel-
oped countries such as United Kingdom, United States, and
Australia (Wells et al., 2000). It is thus expected that laws and legal
institutions to progress in tandem with societal demand for corpo-
rate manslaughter where present laws protects managers from
prosecution (Flin, 1998).
3.3.4. Social and legislation reform
It is also evident from the data that subsequent these disasters,
there is an establishment of social entity, formulation of new leg-
islations, or amendment of laws and regulations take place in the
society as shown in Table 4. The ndings and recommendations
of the inquiries had enabled the Parliament to enact legislations
or repeal prevailing ones, which are found to be obsolete. In addi-
tion they are used to improve the present practices of the govern-
ment agencies or private organizations. As evidenced from the
data, there was some form of social and legislative reforms that
 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295 1293

Table 4
Social and legislation reform.

Disaster
Four-Story Building collapse Kuala Lumpur, 19
October 1968
Collapse of Ferry Terminal 31 July 1988
Fire at Religious School Tauqiah 22 September
1989
Fire and Explosions of Bright Sparklers 7 May 1991
Fire and Explosion at Port Kelang 20 June 1992
Collapse of Highland Towers 11 December 1993
Reform
 On 13 Jun 1974, Street, Drainage and Building Act 1974 (Act 133) was gazetted.
 Uniform Building by Law 1984 came into force under Gazette Notication 5178/85 on 1 January 1986.
 Introduction of new legislation, licensing and registration of building contractors.
 Formation of National Building Joint Council.
 Legislation introduced for the safety of workers and the public at construction site.
 The posts in the Security Department has been declared essential posts, thus require provision of living
quarters for the personnel.
 Operating instructions, showing the limitations of the use of the jetty is made compulsory and kept at all
times in the ofces of the Assistant General Manager in charge of operations and of the Ferry Manager.
 Erection of additional barrier to the line of turnstile in order to keep pressure away from the waiting area.
 The waiting area was required to be divided into sections so as to disperse the load.
 Amendments made to Education Act 1961.
 Amendments made to The Street, Drainage and Building Act (Act 133) 1974 and its subsidiary laws.
 Full enforcement of all subsidiary laws under Fire Services Act 1988.
 Amendments and total enforcement of the Enactment of Control of Religious Schools.
 Amendments to Enactment of State Islamic Affairs Administration.
 Commencement of the formulation of Occupational Safety and Health Act 1994 which is to replace the
Factory and Machinery Act 1967.
 Government banning sale and manufacturing of reworks in the country.
 Formation of HAZMAT teams in the Fire and Rescue Department.
 Maritime Department of Peninsular Malaysia to enforce all the laws and regulations related to international
shipping in particular the Merchant Shipping Ordinance 1952 and all the procedures formulated under it.
 Amendments to Merchant Shipping Ordinance 1952.
 Development of procedure for unloading of hazardous cargo in any port as required by Federation Port Rules
1953, Rules 37 (1).
 Petroleum inspectors that are appointed under Section 38(1) of Petroleum Act 1984 (Safety Procedures) to be
given proper training and courses with regards to their roles and responsibilities.
 Formulation of regulations regarding installation, storage, handling and re prevention under Section 45 of
Petroleum Act 1984.
 Full enforcement of Port Authorities Act 1963 and Port Authority By-Laws 1965.
 The Inland Major Disaster Management Mechanism (Directive 20) was formulated.
 Formation of the Special Malaysia Disaster Assistance and Rescue Team (SMART).
 Section 70 of The Street, Drainage and Building Act (Act 133) 1974 was amended in 1994 which gives local
authorities the power to impose additional conditions.
 Section 99 was added to The Street, Drainage and Building Act, regarding the need to appoint qualied
accredited checker for slope stability for hill-site development projects.

took place after the disasters. These reforms could be further en-
hanced if there was a monitoring body to overseer the implemen-
tation of recommendations arising out of disaster inquiries.
4. Conclusion
From the analysis of the data above, it is evident that events
associated with socio-technical disaster appear to encompass three
distinct periods namely pre-disaster, disaster and post-disaster
consecutively as proled by Richardson (1994). Within each peri-
od, there exists different phases, each with its distinctive features
and characteristics. However successive phase evolves into the
next within a time frame, which varies from one disaster to the
other.
Pre-disaster period is the time before the occurrence of the
disaster. It was found to be consisted of three phases namely oper-
ation, incubation, forewarning and activation. Within the incuba-
tion period, latent errors accumulated and remained buried
within the system. The length of the incubation period varies be-
tween disasters from one (Four-Story Building) to nineteen years
(Collapse of Highland Towers). The length of the incubation period
varies between disasters where similar ndings were also made by
Turner (1978) and Ibrahim et al. (2002). Intertwined within this
period, accidents and negative events occurred which represented
warnings that something was not right and acceptable. Disregards
and misunderstanding of these warnings, the disaster was later set
in motion by a triggering event in the activation phase.
The disaster period embraces two phases, namely onset and
rescue and recovery. The onset of the disaster was found to be trig-
gered by unsafe act of an individual or unsafe condition such as
overloading, which is identiable directly to the cause of the disas-
ter. Rescue and recovery phase follows suit in order to save lives,
properties and return to normalcy. Shortcomings in the response
and rescue were apparent particularly on co-ordination between
various responding agencies, lack of proper rescue equipment
and skills.
Post-disaster period was found to consist of four phases: in-
quiry and reporting; feedback; social justice; and social and legis-
lation reforms. Inquiry and reporting phase commenced with
investigations conducted into the disasters in order to determine
the causes identify culpability and provide recommendations to
prevent future recurrences. Feedback phase is the receipt and
implementations of recommendations by relevant organizations.
However implementation of recommendations by both the
respective public and private organizations was found to be very
weak.
Social justice phase is the redress undertaken by victims to seek
justice by taking appropriate course of legal actions. Court cases
are still pending for victims of two of the disasters (Bright Spar-
klers and Highland Towers) studied. The lengthy legal battle thus
presents a second victimization to victims due to evasive and
non-responsive attitude of authorities and it signals an end to their
normalcy. Social and legislation reforms took place ensuing some
of these disasters. There is an establishment of social entity such
as formation of specialized bodies, amendment and formulation
of new legislations such as Uniform Building by Laws (UBBL),
1294 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295

Table 5
Sequential development of socio-technical disasters in Malaysia.

Period Phase
Pre-disaster I. Operation Socio-technical system is in operation
II. Incubation The accumulation of latent failures, warnings, and deviations from the norms
III. Forewarning Errors surfaced as near misses, accidents or events which represent early warning signs.
IV. Activation Specic action or events identiable directly to cause the disaster
Disaster V. Onset The disaster itself
VI. Rescue and recovery Involves attempts to save life, properties and return to normalcy
Post-disaster VII. Inquiry and reporting Investigations after the disaster to identify causes and seek recommendations to avoid a recurrence
VIII. Feedback The receipt and implementation of the recommendations from the inquiry by the organization concerned
IX. Social justice Appropriate course of legal actions taken to those who contravened the laws related to the disaster
X. Social and legislation reform Formation of specialized bodies, amendment and introduction of acts, laws and regulations

Table 6
Summary of various developmental disaster models.

Period Man-made disaster model Industrial crises model Systems failure and cultural IbrahimRazis pre- AiniRazis socio-technical
(Turner, 1976) (Shrivastava et al., 1988) readjustment model (Toft condition phase model disaster model (2006)
and Reynolds, 1999) (Ibrahim et al. (2002))
Pre-disaster Stage Phase Stage Phase Phase
I. Normal starting point I. Pre-crisis conditions 1. Incubation 1. Generation of errors I. Operation
2. The operational socio- 2. Accumulation of errors II. Incubation
technical system
3. Warning
II. Incubation II. Triggering event 4. Corrections III. Forewarning
5. Unsafe conditions
6. Triggering event IV. Activation
III. Precipitating event 3. Precipitating event 7. Defences
Disaster IV. Onset III. Crisis extension 4. Disaster 8. Disaster V. Onset
V. Rescue and salvage 5. Rescue and salvage VI. Rescue and recovery
Post-disaster VI. Cultural adjustment IV. Crisis resolutions 6. Inquiry and reports VII. Inquiry and reporting
VIII. Feedback
7. Feedback IX. Social justice
X. Social and legislation
reform

and formulation of policies such as the Land Disaster Management Acknowledgement

and Relief Policy (Directive 20).
The disaster sequence model developed from the study consists
of ten phases: operation; incubation; forewarning; activation; on-
set; rescue and recovery; inquiry and reporting; feedback; social
justice; and social and legislation reform. This model advances
two new phases which are social justice and social and legislation
reform to be included in the post-disaster period of socio-technical
disasters (Table 5). Similarities and differences with other disaster
developmental models are as illustrated in Table 6.
The above ndings demonstrate that socio-technical disasters
are not sudden cataclysmic events but they evolved in phases
with long developmental period. Identication of the phases of
disasters would reveal the patterns of disaster development in
the country. With the understanding of the phases of develop-
ment of socio-disasters in the country, it then become possible
for individual organization to identify features and incidences
that if allowed to accumulate may develop into potential disaster.
Hence recognition of these phases will enable organizations to
take remedial actions before an adverse event occurs. This pro-
vides a tool for organizational and institutional diagnosis of vul-
nerability and risks. The ndings may also help policy makers
in the formulation of effective holistic safety and emergency man-
agement at the level of individual, community, industries, non-
governmental organizations and government at the local and
federal levels. With future disasters envisaged to be complex, bor-
derless and extensive in their impacts, empirical research and ex-
change of information is essential if we are to maintain our levels
of prediction and controls. Thus this study is a step forward in
that direction.
The authors wish to thank individuals and organizations, both
local and abroad, which have furnished materials, ideas and infor-
mation that had made this research feasible.
References
Baum, A., Fleming, I., Singer, J.E., 1983. Coping with victimization by technological
disaster. Journal of Social Issues 39, 117138.
Bignell, V., 1999. Methods and case studies for teaching and learning about failure
and safety. European Journal of Engineering Education 24 (3), 311342.
Blockley, D., 1998. Managing proneness to failures. Journal of Contingencies and
Crisis Management 6 (2), 7679.
Bogdan, R.C., Biklen, S.K., 1982. Qualitative Research for Education: An Introduction
to Theory and Methods. Allyn and Bacon Inc., Boston.
Bowonder, B., Kasperson, J.X., Kasperson, R.E., 1985. Avoiding future Bhopal.
Environment 27 (8), 621.
Bryman, A., 2001. Social Research Methods. Oxford University Press, New York.
Cavaye, A.L.M., 1996. Case study research: a multi-faceted research approach for IS.
Information Systems Journal 6, 227242.
Clarke, Rt. Hon Lord Justice, 2000. Thames Safety Inquiry: Final Report, Cm 4558.
HMSO, London.
Cronbach, L.J., 1975. Beyond the two disciplines of scientic psychology. American
Psychologist 30, 116127.
Darke, P., Shanks, G., Broadbent, M., 1998. Successfully completing case study
research: Combining rigour, relevance and pragmatism. Info Systems 8, 273
289.
Drogaris, G., 1993. Major Accident Reporting System: Lessons Learned from
Accidents Notied. Elsevier, Netherlands.
Fink, S., 1986. Crisis Management: Planning for the Inevitable. American
Management Association, New York.
Flin, R., 1998. Safety condition monitoring: lessons from man-made disasters.
Journal of Contingencies and Crisis Management 6 (2), 8892.
Freudenburg, W.R., 1997. Contamination, corrosion and the social order: an
overview. Current Sociology 45 (3), 1939.
 M.S. Aini, A. Fakhrul-Razi / Safety Science 48 (2010) 12861295
Gilbert, C., 1998. Studying disaster. Changes in the main conceptual tools. In:
Quarantelli, E.L. (Ed.), What is a Disaster? Perspectives on the Question.
Routledge, London, pp. 1118.
Gill, D.A., Picou, J.S., 1998. Technological disaster and chronic community stress.
Society & Natural resources 11 (8), 795816.
Glaser, B.G., Strauss, A.L., 1967. The Discovery of Grounded Theory. Aldine, Chicago.
Granot, H., 1998. The dark side of growth and industrial disasters since the Second
World War. International Journal of Disaster Prevention and Management 7 (3),
195204.
Hooke, W.H., 2000. U.S participation in international decade for natural disaster
reduction. Natural Hazards Review 1 (1), 29.
Ibrahim, M.S., Fakhrul-Razi, A., Aini, M.S., Sharif, S., Mustapha, S., 2002.
Technological man-made disaster precondition phase model for major
accidents. International Journal of Disaster Prevention and Management 11
(5), 380388.
Ibrahim, M.S., Fakhrul-Razi, A., Aini, M.S., 2003. Fire incident at a renery in West
Malaysia: the causes and lessons learned. Journal of Loss prevention in the
Process Industries 16, 297303.
Loftland, J., Loftland, L., 1995. Analyzing Social Settings: A Guide to Qualitative
Observation and Analysis. Wadsworth, California.
Maurino, D.E., 2000. Human factors and aviation safety: what the industry has,
what the industry needs. Ergonomics 43 (7), 952960.
McEntire, D.A., 1997. Reecting on the weaknesses of the international community
during the IDNDR: some implications for research application. International
Journal of Disaster Prevention and Management 6 (4), 221233.
Merriam, S.B., 1988. Case Study Research in Education. Jossey-Bass, San Francisco,
California.
Perrow, C., 1984. Normal Accidents: Living with High Risk Systems. Basic Books,
New York.
Picou, J.S., Marshall, B.K., Gill, D.A., 2004. Disaster, litigation and the corrosive
community. Social Forces 82 (4), 493523.
Pugsley, A.G., 1969. The engineering climatology of structural accidents. Paper
presented at International Conference on Structural Safety and Reliability,
Washington (April).
Reason, J., 1997. Managing the Risks of Organizational Accidents. Ashgate Aldershot,
United Kingdom.
Ren, C.H., 2000. Understanding and managing the dynamics of linked crisis events.
International Journal of Disaster Prevention and Management 9 (1), 1217.
1295
Richardson, B., 1994. Socio-technical disasters: prole and prevalence. International
Journal of Disaster Prevention and Management 3 (4), 4169.
Rosenthal, U., 1998. Future disasters, future denitions. In: Quarantelli, E.L. (Ed.),
What is a Disaster? Perspectives on the Question. London, Routledge, pp. 146
159.
Roush, W., 1993. Learning from technological disasters. Technology Review 96 (6),
5058.
Shrivastava, P., 1994. The evolution of crisis research. Journal of Contingencies and
Crisis Management 2 (1), 1020.
Shrivastava, P., Mitroff, I.I., Miller, D., Miglani, A., 1988. Understanding industrial
crisis. Journal of Management Studies 25 (4), 285303.
Silverman, D., 1993. Interpreting Qualitative Data: Methods for Analyzing
Qualitative Data. Sage Publication, London.
Sofaer, S., 1999. Qualitative methods: what are they and why use them? HSR:
Health Services Research 34 (5), 11011118. Part II (December).
Strauss, A., Corbin, J., 1994. Grounded theory methodology: an overview. In: Denzin,
N., Lincoln, Y. (Eds.), Handbook of Qualitative Research. Sage Publication,
Thousand Oaks, pp. 273285.
Toft, B., Reynolds, S., 1994. Learning from Disasters: A Management Approach.
Butterworth-Heinemann, Oxford.
Toft, B., Reynolds, S., 1999. Learning from Disasters: A Management Approach,
second ed. Perpetuity Press, London.
Turner, B.A., 1976. The development of disasters a sequence model for the analysis
of the origin of disasters. Sociological Review 24 (4), 753775.
Turner, B.A., 1978. Man-made Disasters. Whykeham Publications, London.
Turner, B.A., 1994. Causes of disaster: sloppy management. British Journal of
Management 5, 215219.
Turner, B.A., Pidgeon, N.F., 1997. Man-made Disasters. Butterworth Heinemann,
London.
Weichselgartner, J., 2001. Disaster mitigation: the concept of vulnerability revisited.
International Journal of Disaster Prevention and Management 10 (2), 8594.
Weick, K.E., 1990. The vulnerable system: an analysis of the Tenerife air disaster.
Journal of Management 16, 571593.
Wells, C., 1999. Inquiring into disasters: law, politics and blame. Risk Management:
An International Journal 7, 19.
Wells, C., Morgan, D., Quick, O., 2000. Disasters: a challenge for the law. Washburn
Law Journal 39, 496525.