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).
management system that allowed the first urologist to be double-booked. 3. The design and operation of the computerized record-keeping system allowed crucial information to be denied to those at the ‘sharp end’. 4. It is also likely that the absence of a terminal in the operating theatre was the result of a goal conflict between cost-cutting and patient safety. Conclusion This event illustrates very clearly how a number of active failures and latent conditions can combine to create a major
exactly the same as another, the various slip categories share many formal characteristics.14 This was a recognition failure leading to the selection of a wrong object or item. An everyday example of this has occurred to me more than once. I have occasionally bought shaving cream in a squeezable tube. On several occasions, I have put shaving cream on my toothbrush. Many factors conspire to produce this error: a. performing a highly routine activity with my mind on other things; b. proximity –
understood and disseminated – yet maybe we need to move on and FRAM could be one of the ways forward. We shall see. Homo erectus did, after all, become homo sapiens. 1 Turner, B. (1978). Man-Made Disasters. London: Wykeham. 2 Turner, B. and Pidgeon, N. (1997). Man-Made Disasters, 2nd edn. London: Butterworth-Heinemann. 3 Macrae, C. (2014). ‘Early Warnings, Weak Signals and Learning from Healthcare Disasters’. BMJ Quality and Safety, published online, 5 March. 4 Macrae, C. (2014). Close Calls:
Management 135 journals 41, 59, 75, 78, 111, 135 Harvard Review 132 Journal of Contingencies and Crisis Management 135 Jowett, Wayne 87–8 JOYO experimental fast breeder reactor 60 JTC’s Chief Medical Officer ?? 74 junior doctors 68–72, 88, 116 Khashe, Yalde 135 King’s Cross Underground Station fire 13, 30–31 knowledge-based mistakes 14, 16 LaGuardia Airport, New York City 131 Lanzarote, Canary Islands 52 latent conditions 2–4, 9–10, 13, 27, 41, 44, 52, 58, 100, 128 latent failures
117 PS 46–9 PSSR 80 publications 76, 115 The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries 9n2, 113n4, 113n5, 135 Man-Made Disasters 99 Managing the Risks of Organizational Accidents 1 System Failure 128 quality assurance systems 58 Queen’s Medical Centre, Nottingham 64n7, 87, 87n1, 88 rail stations 30, 35, 45, 47 railways 31 accidents 4, 44 employees of 49 underground 30 Rasmussen, Jens 79, 105–7 reactors 133–4 experimental fast breeder 60 nuclear 5 Reason,