TMI control room An ongoing thread of posts here is concerned with organizational causes of large technology failures. The driving idea is that failures, accidents, and disasters usually have a dimension of organizational causation behind them. The corporation, research office, shop floor, supervisory system, intra-organizational information flow, and other social elements often play a key …
Patient safety
An issue which is of concern to anyone who receives treatment in a hospital is the topic of patient safety. How likely is it that there will be a serious mistake in treatment -- wrong-site surgery, incorrect medication or radiation dose, exposure to a hospital-acquired infection? The current evidence is alarming. (Martin Makary et al …
Safety culture or safety behavior?
Deepwater Horizon disaster Andrew Hopkins is a much-published expert on industrial safety who has an important set of insights into the causes of industrial accidents. Much of his career has focused on the oil and gas industry, but he has written on other sectors as well. Particularly interesting are several books: Failure to Learn: The BP …
What the boss wants to hear …
According to David Halberstam in his outstanding history of the war in Vietnam, The Best and the Brightest, a prime cause of disastrous decision-making by Presidents Kennedy and Johnson was an institutional imperative in the Defense Department to come up with a set of facts that conformed to what the President wanted to hear. Robert McNamara …
Regulatory failure
When we think of the issues of health and safety that exist in a modern complex economy, it is impossible to imagine that these social goods will be produced in sufficient quantity and quality by market forces alone. Safety and health hazards are typically regarded as "externalities" by private companies -- if they can be …
Empowering the safety officer?
How can industries involving processes that create large risks of harm for individuals or populations be modified so they are more capable of detecting and eliminating the precursors of harmful accidents? How can nuclear accidents, aviation crashes, chemical plant explosions, and medical errors be reduced, given that each of these activities involves large bureaucratic organizations …
Technology lock-in accidents
Organizational and regulatory features are sometimes part of the causal background of important technology failures. This is particularly true in the history of nuclear power generation. The promise of peaceful uses of atomic energy was enormously attractive at the end of World War II. In abstract terms the possibility of generating useable power from atomic …
Nuclear accidents
Nuclear fission is one of the world-changing discoveries of the mid-twentieth century. The atomic bomb projects of the United States led to the atomic bombing of Japan in August 1945, and the hope for limitless electricity brought about the proliferation of a variety of nuclear reactors around the world in the decades following World War …
Gaining compliance
Organizations always involve numerous staff members whose behavior has the potential for creating significant risk for individuals and the organization but who are only loosely supervised. This situation unavoidably raises principal-agent problems. Let's assume that the great majority of staff members are motivated by good intentions and ethical standards. That means that there are a …
The culture of an organization
Large partitioned office, overview (B&W) It is often held that the behavior of a particular organization is affected by its culture. Two banks may have very similar organizational structures but show rather different patterns of behavior, and those differences are ascribed to differences in culture. What does this mean? Clifford Geertz is one of the …
Understanding Society 