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

image: diagram of molten salt reactor 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 …

Nuclear accidents

diagrams: Chernobyl reactor before and after 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 …

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

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 most articulate theorists of culture …

Organizational dysfunction

What is a dysfunction when it comes to the normal workings of an organization? In order to identify dysfunctions we need to have a prior conception of the "purpose" or "agreed upon goals" of an organization. Fiscal agencies collect taxes; child protection services work to ensure that foster children are placed in safe and nurturing …

Corruption and institutional design

Robert Klitgaard is an insightful expert on the institutional causes of corruption in various social arrangements. His 1988 book, Controlling Corruption, laid out several case studies in detail, demonstrating specific features of institutional design that either encouraged or discouraged corrupt behavior by social and political actors. More recently Klitgaard prepared a major report for the …

How organizations adapt

Organizations do things; they depend upon the coordinated efforts of numerous individuals; and they exist in environments that affect their ongoing success or failure. Moreover, organizations are to some extent plastic: the practices and rules that make them up can change over time. Sometimes these changes happen as the result of deliberate design choices by individuals inside or …

Accident analysis and systems thinking

Complex socio-technical systems fail; that is, accidents occur. And it is enormously important for engineers and policy makers to have a better way of thinking about accidents than is the current protocol following an air crash, a chemical plant fire, or the release of a contaminated drug. We need to understand better what the systems …

System safety engineering

source: Nancy Leveson, Engineering a Safer World: Systems Thinking Applied to Safety Why do complex technologies so often fail, and fail in such unexpected ways? Why is it so difficult for hospitals, chemical plants, and railroads to design their processes in such a way as to dramatically reduce the accident rate? How should we attempt to …

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