Understanding organisational and cultural precursors to events

Abstract

General rightsThis document is made available in accordance with publisher policies. Please cite only the published version using the reference above. Reviewing the collective findings from investigations into a range of major events in high-hazard industries has led to the conclusion that there is a need to develop greater resilience to the organisational and cultural causes of these events. This requires more rigorous methods for identifying disaster precursors and for supporting intervention design. A study of the organisational and cultural precursors relating to 12 major events across several industries revealed shared precursors in areas such as leadership, operational attitudes and behaviours, communication, risk analysis, learning and oversight and scrutiny. This has enabled statements of good practice to be developed, together with question sets that can be used by regulators and the industry to profile organisational risk management resilience and thereby drive organisational learning. The research shows that the processes of incubation and evolution of disaster events can be complex and exercising control therefore requires development of more sophisticated 'tools' than are currently available. It has revealed repeating patterns of failure and the importance of psychological and behavioural factors which have led to poor decision-making. Causal loop modelling is being used to capture these patterns to facilitate the design of more informed interventions. Emerging issues and new approaches being developed are discussed and examples given.

Understanding Reporting and Problem-Solving Behaviors in a High Reliability Organization: A Case Study in a Spanish Nuclear Company

“…Numerous studies agree on the fact that leadership, of both executives and managers, is the crucial element determining the system's operational performance success (Reason, 1997). In turn, leadership influences the existence of a "blame-free" organizational culture that promotes reporting (Behari, 2019;R. Taylor et al, 2017).…”

“…Similarly, a lack of reporting would anticipate future operational problems. In this regard, a study reviewing twelve significant events into depth shows that organizational unreported precursors existed for many of such events (R. Taylor et al, 2017). The extent to which these reporting systems are used seems to indicate the level of organizational attention to safety.…”

Editorial

“…The contribution by Taylor et al (2017) also focuses on human and organisational issues associated with failures. By studying a number of major events in high-hazard industries they identified organisational and cultural precursors to these events.…”