Prevention of falling objects Risk, Uncertainty, Organisation & - - PowerPoint PPT Presentation

University of Stavanger uis.no

03.09.2013

“Prevention of falling objects” “Risk, Uncertainty, Organisation & Culture”

Ole Andreas Engen

Professor, SEROS

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Objectives

• This lecture will place organisational events, incidents and

accidents – such as falling obj ects - in a conceptual and theoretical context

• This implies to discuss basic concepts of risk, uncertainty and
• rganisational challenges handling such phenomena
• It also implies to discuss what organisational barriers that exist

in order to reduce risk and reduce uncertainties associated with events such as falling obj ects

• Finally, from theory to practise i.e. suggesting some practical

implications.

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What is risk

• Risk is probabilities X consequences
• Risk is equal to the two dimensional combination of

events/ consequences and associated uncertainties

• Risk refers to uncertainty about, and severity of the

consequences with respect to something humans value What definition of risk that is applicable or relevant depends on how much we know about the event, the context of the event and the degree of uncertainty.

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Risk

Complexity

Uncertainty Ambiguity

Interpretative:

the relevance, meaning and implications of the basis for the decision making

Normative:

The values to be protected and the priorities to be made

Aleatoric:

variability represented by distribution possible values e.g. roll of a fair dice

Epistemic:

Basic lack of knowledge about fundamental parametres e.g. climate change

The Concept of Risk

Analytical concept

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What are organisational accidents?

• Often catastrophic events that occur in a complex

technological and organisational setting

• The necessary condition for an organisational accident is the

rare conj uction of a set of holes in succesive defences, allowing to come into damaging contact with people and assets

• An accident traj ectory passing through corresponding holes in

the layers of defences, barriers and safeguards.

• Concepts: Active failures, latent conditions. It is an
• rganisational goal to mobilise resources in order to reduce

risk for such events to occur.

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Risk perception Events, incidents, accidents

Propensities of risk

Balancing behaviour Reward Money, power, love, glory, food, sex, rushes of adrenaline, control ... Money, health, life, status, self-esteem, embarrassment, j ail, loss of control ...

The Risk Thermostat

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Organisational accident and incidents

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PROBLEM DRAW UPON PAST EXPERIENCE DEVELOP AND IMPLEMENT SOLUTION PROBLEM BRING IN NEW KNOWLEDGE DRAW ON PAST EXPERIENCE IMPLEMENT NEW MORE EFFECTIVE SOLUTION

(a) Single Loop Learning (b) Double Loop Learning

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«Engineering a safety culture»

Just Culture Reporting Culture Flexible Culture Informed Culture Learning Culture

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Safety culture

• Culturally embedded
• Top down
• Focus on interaction & groups
• Unveil the fundamental values
• f the organisations
• Change management
• Understand conditions for

compliance

• Behaviour based
• Bottom up
• Frontline employees
• Focus on activities
• Individual measure
• Provide support
• Continous improvement

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Organisational typologies

Pathological Bureaucratic Generative Don’ t want to know May not find out Actively seek it Messengers «are shot» Messengers are listened to if they arrived Messengers are trained and rewarded Responsibility is shirked Responsibility is compartmentalized Responsibility is shared Failure is punished or concealed Failures lead to local repairs Failures lead to far reaching reforms New ideas are actively discouraged New ideas often present problems New ideas are welcomed

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Experiences from the industry: Investigation, measures and learning

• S

carce and rigid timelimits for investigations.

• Lacking routines for spreading of knowledge from

investigations

• Overproduction of measures. (” Tiltakstretthet” )
• ” Incident-investigation-order-measures-incident..» creates

stress and noise in the organisation.

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Power and learning

• Learning requires openness, sincerity and honesty.
• The ability to learn is weakened by struggles between

different social groups i.e.management and unions, and between the unions and other stakeholders within complex

• rganisational systems
• Incidents are used to gain power and influence. Creates noise

and a resulting lack in the capacity to handle HS

• E. It also

disturbs abilities of compliance

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Power & learning

• S

trong beliefs in systems and regulations among upper management

• Excessive belief in systems may produse overspesialisation and

increased organisational complexity

• Result: increased gap between procedures and practice
• We find signs of these types of developments in the industry

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Risk, Uncertainty and Organisational Accidents

• How to develop correct risk perceptions & understanding
• How to make organsiational arrangements in order to deal with

uncertainty

• How to reduce number of unsafe acts, active failures and

latent conditions

• What organisational barriers exist when it comes to

establishing effective risk management, leadership and compliance and engineering a robust safety culture.

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Management system Identified challenges Improvement areas Decision making Competence/staffing Management perspective Power relations Investigation Systems for knowledge sharing Interface towards the suppliers New technology and

• rganisational adaption

Criticism Complexity Power Investigation and measures Means for knowledge sharing Managing

• rganisational

interface

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Combining risk descriptions with managerial and organisational efforts

• Risk in organisations - requires individual identifications
• Risk in organisations - requires organisational slack &

redundancy

• Risk in organisations- requires an «open safety culture» freed

from patolhogical traits

• Risk in organisations- requires an organisational culture

characterised by balanced power relations and trust between the different groups.

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Risk and organisational precautionary principles

• The level of uncertainty will challenge the work of developing

and implementing organisational precautionary principles

• The degree of organisational precautionary principles has to

balance with principles of cost efficiency

• Developing precautionary principles handling risk is also to

establish organisational principles for double loop learning

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Thank You!

Hopefully not the practise!!!!