Organizational Accidents Revisited
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Managing the Risks of Organizational Accidents introduced the notion of an ’organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ’individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardized causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the ’raw data’ for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ’error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).
track ahead was clear of the IP train. However, for reasons that will become clearer later, the IP was halted around a bend and out of sight of the oncoming W354. Train W354 crashed into a ‘motorail’ car at the end of the IP and seven passengers were killed instantly. The driver of W354 managed to avoid serious injury as he ran back through the first carriage when a collision appeared imminent. Dozens of passengers on both trains sustained injuries – 50 of them were taken to hospital by
failed to implement safety improvements after the disaster. In 2011, BP announced it was selling the refinery in order to pay for ongoing compensation claims and remedial activities following the Deepwater Horizon disaster in 2010. This will be discussed in the next case study. Case Study 9: Deepwater Horizon in the Gulf of Mexico18 Deepwater Horizon was a semi-submersible, mobile, floating, dynamically positioned oil rig, operated mainly by BP and, at the time of the explosion, was situated in
knowledge-based mistakes we have exhausted our stock of pre-packaged solutions and have to tackle a novel situation by resorting to the highly fallible of business of thinking ‘on the hoof’. Although people can be quite good at coming up with fresh solutions when they have plenty of time to reflect, they generally perform badly under the more usual conditions of time pressure, strong emotion and the prospect of imminent disaster (e.g., Air France Flight 447). In this situation we are forced to
twist and turn. Fittingly, he was appointed Daichi’s (the sister plant) Chief Decommissioning Officer in April 2014. The Ingredients of Heroic Recovery: What is the ‘Right Stuff’? What makes for heroic recoveries? This is a question I have struggled with at length in a previous book. The short and unsatisfactory answer is that it involves the right person in the right place at the right time doing the right thing. I don’t believe that this statement is untrue, but it is nevertheless unhelpful
varied 71 safety 23–5, 27–32, 34, 57, 62, 80, 83, 91, 96, 99–103, 106, 113, 122 culture 52, 64, 81, 83, 103 gauging 29 making a line management responsibility 31 management 3, 29, 72, 111, 119, 126 occupational 81 problems 32 procedures 80 processes 24, 80 responsibilities 30, 32 violations 81, 124 Safety Case 24–6 safety management systems, see SMS senior house officers see SHOs serious hazards of transfusion see SHOT share prices 124–5 Sheen, Justice 127 Shell Co. 17, 29, 31,