THE ORGANIZATIONAL ACCIDENT .1 BASIC SAFETY CONCEPTS
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2.4.6 Decisions by line management may result in inadequate training, scheduling conflicts or neglect of workplace
precautions. They may lead to inadequate knowledge and skills or inappropriate operating procedures. How well line management and the organization as a whole perform their functions sets the scene for error- or violation-producing
conditions. For example: How effective is management with respect to setting attainable work goals, organizing tasks and resources, managing day-to-day affairs, and communicating internally and externally? The decisions made by company
management and regulatory authorities are too often the consequence of inadequate resources. However, avoiding the initial cost of strengthening the safety of the system can facilitate the pathway to the organizational accident.
2.4.7
Figure 2-3 portrays the Reason model in a way that assists in understanding the interplay of organizational and management factors i.e. system factors in accident causation. Various defences are built deep into the aviation
system to protect against fluctuations in human performance or decisions with a downside at all levels of the system i.e. the front-line workplace, supervisory levels and senior management. Defences are resources provided by the system to
protect against the safety risks that organizations involved in production activities generate and must control. This model shows that while organizational factors, including management decisions, can create latent conditions that could lead to
breaches in the system’s defences, they also contribute to the robustness of the system’s defences
2.5 THE ORGANIZATIONAL ACCIDENT 2.5.1
The notion of the organizational accident underlying the Reason model can be best understood through a building-block approach, consisting of five blocks Figure 2-4.
Figure 2-3. A concept of accident causation
Latent conditions trajectory
Defences People
Accident Workplace
Organization
Techn ology
Train ing
Regu lation
s Errors
and violatio
ns Workin
g conditio
ns Manag
ement decisio
ns and organ
ization al
proces ses
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Figure 2-4. The organizational accident
2.5.2 The top block represents the organizational processes. These are activities over which any organization
has a reasonable degree of direct control. Typical examples include: policy making, planning, communication, allocation of resources, supervision and so forth. Unquestionably, the two fundamental organizational processes as far as safety is
concerned are allocation of resources and communication. Downsides or deficiencies in these organizational processes are the breeding grounds for a dual pathway towards failure.
2.5.3
One pathway is the latent conditions pathway. Examples of latent conditions may include: deficiencies in equipment design, incompleteincorrect standard operating procedures, and training deficiencies. In generic terms, latent
conditions can be grouped into two large clusters. One cluster is inadequate hazard identification and safety risk management, whereby the safety risks of the consequences of hazards are not kept under control, but roam freely in the
system to eventually become active through operational triggers. 2.5.4
The second cluster is known as normalization of deviance, a notion that, simply put, is indicative of operational contexts where the exception becomes the rule. The allocation of resources in this case is flawed to the
extreme. As a consequence of the lack of resources, the only way that operational personnel, who are directly responsible for the actual performance of the production activities, can successfully achieve these activities is by
adopting shortcuts that involve constant violation of the rules and procedures. 2.5.5
Latent conditions have all the potential to breach aviation system defences. Typically, defences in aviation can be grouped under three large headings: technology, training and regulations. Defences are usually the last safety
net to contain latent conditions, as well as the consequences of lapses in human performance. Most, if not all, mitigation strategies against the safety risks of the consequences of hazards are based upon the strengthening of existing
defences or the development of new ones.
Organizational processes
Workplace conditions
Latent conditions
Active failures
Defences
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2.5.6 The other pathway originating from organizational processes is the workplace conditions pathway.
Workplace conditions are factors that directly influence the efficiency of people in aviation workplaces. Workplace conditions are largely intuitive in that all those with operational experience have experienced them to varying degrees,
and include: workforce stability, qualifications and experience, morale, management credibility, and traditional ergonomics factors such as lighting, heating and cooling.
2.5.7 Less-than-optimum
workplace conditions foster active failures by operational personnel. Active failures can
be considered as either errors or violations. The difference between errors and violations is the motivational component. A person trying to do the best possible to accomplish a task, following the rules and procedures as per the training
received, but failing to meet the objective of the task at hand commits an error. A person who willingly deviates from rules, procedures or training received while accomplishing a task commits a violation. Thus, the basic difference
between errors and violation is intent. 2.5.8
From the perspective of the organizational accident, safety endeavours should monitor organizational processes in order to identify latent conditions and thus reinforce defences. Safety endeavours should also improve
workplace conditions to contain active failures, because it is the concatenation of all these factors that produces safety breakdowns Figure 2-5.
Figure 2-5. The perspective of the organizational accident
R e
in fo
rc e
Organizational processes
Workplace conditions
Latent conditions
Active failures
Defences
Improve Identify
Monitor
C o
n ta
in
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2.6 PEOPLE, CONTEXT AND SAFETY — THE SHEL MODEL 2.6.1