Managing the Risks of Organizational Accidents introduced the notion of
an 'organizational accident'. These are rare but often calamitous events
that occur in complex technological systems operating in hazardous
circumstances. They stand in sharp contrast to 'individual accidents'
whose damaging consequences are limited to relatively few people or
assets. Although they share some common causal factors, they mostly have
quite different causal pathways. The frequency of individual accidents -
usually lost-time injuries - does not predict the likelihood of an
organizational accident. The book also elaborated upon the widely-cited
Swiss Cheese Model. Organizational Accidents Revisited extends and
develops these ideas using a standardized causal analysis of some 10
organizational accidents that have occurred in a variety of domains in
the nearly 20 years that have passed since the original was published.
These analyses provide the 'raw data' for the process of drilling down
into the underlying causal pathways. Many contributing latent conditions
recur in a variety of domains. A number of these - organizational
issues, design, procedures and so on - are examined in close detail in
order to identify likely problems before they combine to penetrate the
defences-in-depth. Where the 1997 book focused largely upon the systemic
factors underlying organizational accidents, this complementary
follow-up goes beyond this to examine what can be done to improve the
'error wisdom' and risk awareness of those on the spot; they are often
the last line of defence and so have the power to halt the accident
trajectory before it can cause damage. The book concludes by advocating
that system safety should require the integration of systemic factors
(collective mindfulness) with individual mental skills (personal
mindfulness).
