No theory forbids me to say "Ah!" or "Ugh!", but it forbids me the bogus theorization of my "Ah!" and "Ugh!" - the value judgments. - Theodor Julius Geiger (1960)

Accidents and disasters are typically unintended, unanticipated, and uncontrollable events. Avoiding disasters involves more than just increasing technical controls: Most accidents and disasters are rooted in social, administrative, or managerial issues. Accidents often result from an incubation period, a buildup of preconditions ("pathogens") and misconceptions over an extended period. These can lead to disaster when triggered by a specific event.

Several indicators suggest a management system may be losing touch with its operational realities. These include tolerating gaps in important information, failure to disclose information, or restricting information access to those who may not fully understand its significance. Rigid hierarchies within organizations can hinder the flow of information. In organizations, senior management may be the last to learn about issues within their organizations, allowing disaster preconditions to develop.

To understand why systems go wrong, engaging with operators and lower-level management is necessary, as they often have insights that can be overlooked by higher-ups. Senior management sometimes holds unrealistic views of their organization, its operations, and vulnerabilities, and suppresses dissenting voices. Senior managers need to be open to alternative views and criticisms from outside the organization.
So called high-reliability organizations, such as air traffic control systems and nuclear-powered aircraft carriers, achieve high levels of reliability and safety. These organizations navigate trade-offs between the need for quick decisions and accurate decisions, hierarchical structures, and involving lower-level personnel, as well as managing information flow. Further, it’s important to cultivate a culture where both managers and employees genuinely care about the consequences of their actions and are open to learning from failures and near-misses.
Organizations often prioritize their goals, sometimes overlooking peripheral factors. Yet, in an open-world environment, they can't always anticipate all relevant variables or prevent interference from other entities. To avert disasters, organizations must adopt a broader, flexible perspective within their systems. Enhanced management practices won't eliminate all catastrophes, but they can substantially lower risks by promoting adaptability, improving team communication, acknowledging external feedback, and considering the potential repercussions of their actions. This approach mitigates human and financial costs, market losses, and damage to corporate reputation resulting from major accidents.
Turner, B.A. (1994), Causes of Disaster: Sloppy Management, in: British Journal of Management, Vol. 5,215-219 (1994).

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