A study of the precursors leading to ‘organisational’ accidents in complex industrial settings

• Published in: Process safety and environmental protection Vol. 93; pp. 50 - 67
• Main Authors: Taylor, Richard H., van Wijk, Lorenzo G.A., May, John H.M., Carhart, Neil J.
• Format: Journal Article
• Language: English
• Published: Elsevier B.V 01.01.2015
• Subjects: Accident precursors; Accidents; Aggregates; Assessments; Business; Catalogues; Hierarchical process modelling; Organisational resilience; Organisational vulnerabilities; Precursors; Resilience; Safety; Socio-technical dynamics models; Systems thinking; Accident precursors; Organisational vulnerabilities; Hierarchical process modelling; Systems thinking; Organisational resilience; Socio-technical dynamics models
• ISSN: 0957-5820; 1744-3598
• DOI: 10.1016/j.psep.2014.06.010

•12 accident investigations are analysed highlighting common organisational issues.•Statements of expectation are derived to address organisational learning issues.•Diagnostic questions are proposed to assess expectations in organisational practice.•Hierarchical process modelling and system dynamics models of issues are considered. This study aggregates the narrative findings from the investigation of 12 accidents or ‘near hits’ across a wide range of industrial settings to build a catalogue of organisational and cultural precursors to accidents. It was found that many were important factors in multiple events. It is argued that by addressing these potential vulnerabilities using the findings and proposed tools based upon them, organisations undertaking safety related activities will not only develop greater awareness of these deeper-lying issues but should be able to better control the risks associated with them. The precursors have been classified under eight headings and examples of key findings from three of these are presented. Statements providing potential defences against the identified vulnerabilities have been developed which should enable organisations to scrutinise the adequacy of existing expectations or requirements within their business. Probing questions have been developed based on the statements which should allow an assessment to be made as to whether these have been ‘embedded’ in the organisation. It is argued that organisational vulnerability tools should be developed to enable a systematic approach to ‘diagnosing’ incubating precursors. It is also argued that there is the potential for further resilience to be achieved through the use of models of the complex dynamics of socio-technical processes within organisations.