Safety

Risk Space—Understanding the Complexity of Operational Risk

As the science has developed, accident-causation models have improved understanding of why accidents happen and how to reduce their likelihood. In more contemporary models, this approach also has been used to improve the understanding of why things go right and how to increase that likelihood.

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How organizations deal with risk has evolved over the years. Well before the publication of the domino theory, engineers were already managing the risks they face from their engineering projects through the use of safety margins. Indeed, everyone manages risk on a daily basis. As we gain experience with the world around us, our understanding of the risks we take and how we run them improves. Infants are not aware of the probability of failure, nor are they aware of the potential consequences. The basic risk equation—probability of failure times consequence equals risk—has to be learned by individuals gaining experience of the world around them and then by their increasing understanding what the risks are that they take and run.

In organizational risk management, this same basic equation is used to understand and manage the risks taken by the organization. Accident-causation theories tried to explain the risks that personnel and the organization were exposed to and increasingly elaborated how organizations failed to manage them properly.

Theories such as the domino theory created a linear understanding of what went wrong. The use of these linear theories enabled a massive reduction in accidents and incidents and probably has been one of the greatest revolutions in industrial operations. The acceptance of their duty of care to their employees by management and an understanding of the severity of impact on operations of serious accidents spurred the use of these theories. This slow revolution in safety understanding probably has saved more lives than any other single idea in the industrial sphere beside the unionization of labor.

Nevertheless, despite the massive success of simple linear theories, they did not adequately address serious industrial accidents. Tragedies such as Piper Alpha, the Herald of Free Enterprise, and the Challenger and Columbia space shuttle disasters have driven the development of more-complex models that are better able to capture the complexity of modern operations. The simple linear accidents described by the older theories still fit within the paradigm of these more-complex-systems theories but did not explain why more-complex accidents occurred. The application of models that contained the nonlinear complexity of accident causation and moved the ascription of agency beyond the frontline have, once again, been able to create another step-change in performance. However, despite the more-sophisticated understand allowed by these models, incidents and accidents still occur. This paper strives to address why the remainder of the possible accidents still occur.

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