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Friday, June 04, 2010

Rare But Catastrophic

Accidents are a fact of life, simply because we are humans and have been created with two key characteristics; (1) decision-making, and (2) limited abilities. Only the creator of the universe has full control over every single element in the universe, ranging from the smallest part of an atom to the largest galaxy.

Personal accidents are very common and their impacts could be trivial to severe, and are usually local. Examples are simple fender benders, a child pushing another one while reaching out for a toy doll, and a house fire.

Organizational accidents on the other hand are less common and their impacts are more significant, and usually devastating and affecting others not related to the organization or its services. The root cause of an organizational impact can be due to an individual choice, a group decision, or a larger organizational error. However, at the end it is within the context of an organization. Individual accidents could also have origins in organizations. Hence, the line of separation between individual and organizational accidents is subtle and often quite not clear. Examples of organizational accidents are aircraft crashes like Air India's recent crash 1, 2, 3, and BP's oil well leak 4, 5, 6.

Key differences between individual and organizational accidents are listed below:

Root Cause Individual or personal error, negligence; poor decision-making; poor personal quality. Accumulated errors; altered relationships between systems and human elements; altered states of the environment due to technological innovations
Impact Local, usually agent and victim could be the same; small to devastating Wide-spread, reaches to uninvolved populations; small to devastating.
Frequency High Low
Predictability Easy Medium
Complexity Low Medium  - High
Survival Rate Medium – High Low – Medium
Defenses Weak or lacking Medium to strong

A main challenge in understanding organizational accidents is defining where the boundaries of the accident end. Both time and causality are seamless and do not have natural boundaries. To best analyze an accident, to prevent it from happening again, one may limit the scope of interest to things that people in the organization can manage. Accidents are usually triggered when some weakness in a defense system appears, the weakness could be a latent condition that exists and turned into an active failure. Latent conditions are similar to pathogens in a human body, they can be present for a long time and might not be detectable, however once triggered they turn into failures leading to immediate accidents. All organizations young and mature, simple and complex include latent conditions within their boundaries. More about latent conditions and active failures in my next post.

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