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Composite model 18.28 Category (A) defences: Preventing initiating event leading to hazard Hazardous event (e.g. outbreak of fire) Figure 18.3: Classic ‘Bow Tie’ Model Chapter 18 – Accident Theory and High-Risk Technologies Category (B) defences: Ameliorating consequences of hazardous event I have combined the ‘Swiss Cheese’ and the ‘Bow Tie’ models to form a composite 3-D model which may prove a useful tool in illustrating how the various layers of defences and the ‘hierarchy’ of preventative and ameliorating measures may be logically placed. Figure 18.4: ‘Composite Model’ Accident trajectory 467
The Nimrod Review The ‘organisational theory’ analytical framework model 18.29 18.30 18.31 468 Since it is impossible to guarantee the elimination of all human error, it is necessary to devise more effective ways of mitigating the consequences of human error in unforgiving situations. 42 The ‘organisational theory’ analytical framework model pioneered by James Reason is a ‘self-monitoring’ process which works in two ways. First, it works in the traditional way of allowing causal failures to be identified by accident investigators and tracked back to their organisational roots in order to prevent recurrence. Second, since the same precise mixture of causes is unlikely to recur, 43 the ‘causal pathways’ model enables ‘pathogen’ auditing of both ‘active’ and ‘latent’ failures within an organisation since this is considered to be the most effective way of managing safety. 44 Analysis of major accidents typically show that the basic safety of a system has eroded due to ‘latent’ errors, and that a more significant contribution to safety can often be expected from, e.g., efforts to decrease the duration of latent errors then from measures to decrease their basic frequency. 45 In terms of remedial implications, therefore, by specifying the organisational and situational factors involved in the causal pathways, it is possible to identify potentially dangerous latent failures before they combine to cause an accident. 46 These conceptual tools can be applied to any event, no matter how trivial. The ‘organisational theory’ analytical framework approach asserts that the starting point for any analysis is the decisions taken in the higher echelons of the system. These decisions, shaped by economic and political factors such as inadequate budgets, deficient planning, and operational pressures, seed organisational pathogens into the system at large. These resident ‘pathogens’ take many forms including ill-defined policies, lack of control over contractors, blurred responsibilities, poor design, specification and construction, lack of foresight or awareness of risks, excessive cost-cutting, managerial oversights, deficient maintenance arrangements, and missing or flawed defences. The negative effects or adverse consequences of these pathogens are transported along two principal pathways to the various workplaces, where they act upon the ‘defences, barriers and safeguards’ to create ‘latent’ failures and upon ‘local working conditions’ to promote ‘active’ failures, i.e. errors, violations and component failures. 47 ‘Local working conditions’ are the factors that influence the efficiency and reliability of human performance in a particular work context. These can conveniently be divided into factors relating to the task and its immediate environment, and those relating to people’s mental and physical states. The authors point out that many such unsafe acts will be committed, but only very few of them will penetrate the defences to bring about damaging outcomes. 48 Major disasters in defended systems are rarely, if ever, caused by one factor, either mechanical or human. Rather, they arise from unforeseen and usually unforeseeable concatenation of several diverse events, each one necessary but singly insufficient. 49 These observations suggested to James Reason an analogy between the breakdown of complex technological systems and the aetiology of multiple-cause illnesses such as cancer and cardiovascular disease. More specifically, there appeared to him to be similarities between latent failures in complex technological systems and resident pathogens in the human body. This metaphor provides useful elucidation in relation to the application of organisational theory and the existence of failures and local triggering events. 50 18.32 The authors of Beyond Aviation Human Factors draw attention to a very important feature of the ‘causal pathways’ model, namely, that there is a clear separation between the ‘active’ and ‘latent’ failure pathways, though both have a common origin in the strategic organisational processes. The reason highlighted for distinguishing the pathways is in order to reflect the differing character of past (and potential) accidents. Accidents such as Challenger, Piper Alpha and The King’s Cross Underground Fire involved little or no ‘active’ failures as proximal causes. In these cases the accident trajectory passed through longstanding ‘latent’ failures 42 See James Reason, Human Error, 1990, page148. 43 Ibid, page 174 44 Ibid, page 210. 45 Ibid, page 180. 46 Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee, Beyond Aviation Human Factors, 1995, page 28. 47 Ibid, See page 82 for an example of the organisational theory analytical framework/causal pathways model, in relation to the Air Ontario Crash at Dryden, Ontario (referred to at paragraph 18.12 above). 48 Ibid, page 9. 49 See James Reason, Human Error, 1990, page 179. 50 Ibid, pages 197-198.
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THE NIMROD REVIEW An independent re
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© Crown Copyright 2009 The text in
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THE LOSS OF RAF NIMROD XV230 A FAIL
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XV230
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2 The Nimrod Review Section Two: Re
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Chapter 1 - Introduction and Summar
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The Nimrod Review Offices and Team
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Executive Summary Introduction Loss
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Chapter 1 - Introduction and Summar
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Coroner’s Inquest Chapter 1 - Int
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Chapter 2 - History of the Nimrod A
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CHAPTER 3 - THE BOARD OF INQUIRY RE
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PART II: PHYSICAL CAUSES
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The Nimrod Review 36 (2) The escape
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The Nimrod Review 40 7. The Cross-F
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The Nimrod Review 72 Description of
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The Nimrod Review 80 of one second,
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The Nimrod Review 82 Maintenance re
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The Nimrod Review 84 Ignition/Leak
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The Nimrod Review 92 The Manufactur
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The Nimrod Review 94 The Procuremen
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The Nimrod Review Analysis 6.19 112
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PART III: NIMROD SAFETY CASE Introd
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PART IV: ORGANISATIONAL CAUSES
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PART V: AFTERMATH Introduction to P
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The Nimrod Review Safety Managers 2
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The Nimrod Review The critical role
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The Nimrod Review 29.6 XV230 29.7 5
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The Nimrod Review FI Fatigue Index
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ACKNOWLEDGEMENTS Acknowledgements A
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