RISK MANAGMENT

Normal Accident Theory

A quick Quiz?

A Day in Your Life

·         You have an important decision meeting downtown.

·         Your spouse has already left. Unfortunately he/she left the glass coffee pot on a lit burner and it cracked.

·         You desperately need your coffee so you rummage around for an old drip coffee pot.

·         You pace back and forth waiting for the water to boil while watching the clock. After a quick cup you dash out the door.

·         You get in your car only to realize that you left your car and apartment keys inside the house.

·         That’s okay. You keep a spare house key hidden outside for just such emergencies.

The Answer----- All of the above reason, Life is a complex system

What Characterizes a Complex System?

A complex system exhibits complex interactions when it has: Unfamiliar, unplanned, or unexpected sequences which are not visible or not immediately comprehensible

Design features such as branching; feedback loops Opportunities for failures to jump across subsystem boundaries.

A complex system is tightly coupled when it has:

1.    Time-dependent processes which cannot wait

2.    Rigidly ordered processes (as in sequence A must follow B) only one path to a successful outcome very little slack (requiring precise quantities of specific resources for successful operation).

What should we do to protect against accidents or mission failure?

Safety is the primary organizational objective.

Redundancy enhances safety: duplication and overlap can make “a reliable system out of unreliable parts.” Decentralized decision-making permits prompt and flexible field level responses to surprises which might occur without notice.

A “culture of reliability” enhances safety by encouraging uniform action by operators. Strict organizational structure is in place, continuous operations, training, and simulations create and maintain a high level of system reliability.

Trial and error learning from accidents can be effective, and can be supplemented by anticipation and simulations.

Normal Accidents - The Reality

Safety is one of a number of competing objectives.

Redundancy often causes accidents. It increases interactive complexity and opaqueness and encourages risk-taking. Organizational contradiction: decentralization is needed for complexity and time dependent decisions, but centralization is needed for tightly coupled systems.

A “Culture of Reliability” is weakened by diluted accountability. Organizations cannot train for unimagined, highly dangerous, or politically unpalatable operations; denial of responsibility, faulty reporting, and reconstruction of history cripples learning efforts of future events that might have or will occur.

What Are We Doing?

Redundancy is no longer the automatic answer. Risk management planning provides alternate approaches. Program responsibility has been moved to the Centers. They are most capable to determine the appropriate level of centralized decision-making. Government’s move from oversight to insight places accountability where it belongs.

Understanding Complexity

      I.        Accident investigators generally focus on: Operator error

    II.        Faulty system design

   III.        Mechanical Failure

  IV.        Procedures

   V.        Inadequate training

  VI.        Environment (including management organization)

 VII.        Many times there is a tendency to cite “operator error” alone as the cause of an accident.

Close-Call Initiative

The Premise: Analysis of close-calls, incidents, and mishaps can be effective in identifying unforeseen complex interactions if the proper attention is applied.

Root causes of potential major accidents can be uncovered through careful analysis. Proper corrective actions for the prevention of future accidents can be then developed.

Human Factors Program Elements

1. Collect and analyze data on “close-call” incidents: Major accidents can be avoided by understanding near misses and eliminating the root cause.

2. Develop corrective actions against the identified root causes by applying human factors engineering.

3. Implement a system to provide human performance audits of critical processes -- process FMEA.

4. Organizational surveys for operator feedback.

5. Stress designs that limit system complexity and coupling.

Summary

Risk Management nominally works with the theory that accidents can be prevented through good organizational design and management. Normal accident theory suggests that in complex, tightly coupled systems, accidents are inevitable. There are many activities underway to strengthen our safety posture.

Risk Management’s new thrust in the analysis of close-calls provides insight into the unplanned and unimaginable.