Identification of Multiparadigmatic Causal Mechanisms of Industrial Accidents.

摘要

Root cause analysis (RCA) methodologies fall short of addressing the sociotechnical causations of industrial accidents by defining the event from a functionalist paradigm instead of invoking a worldview perspective. The unaddressed multiparadigmatic causations have the potential to cause accidents to repeat themselves as evidenced by RCA practitioners complaining that problem reoccurrence often persists after multiple RCA interventions. The research question for the current study centered on the exploration of the role of an organizational multiparadigmatic map (OMM) based on critical systems practice (CSP) in the performance of an RCA to identify the multiparadigmatic causal mechanisms of sociotechnical accidents, process failures, and near misses in an industrial setting. Focusing on a random sample of industrial organizations with at least 30 employees in metropolitan Atlanta, Georgia, an exploratory case study was conducted at a water reclamation plant where an RCA was facilitated using an OMM to identify the multiparadigmatic causal mechanisms associated with a near miss. Semistructured interviews of 17 employees were coded based on the CSP paradigms and aggregated to corrective maintenance reports before being analyzed and interpreted. Results indicated that the use of an OMM in an RCA helped identify the causal mechanisms and contributed to a broad understanding of the underlying problems that caused the near miss. This study contributes to a positive social change by enabling operations and safety managers to identify the causal mechanisms of sociotechnical problems through the use of an OMM-based RCA methodology. Effective mitigation strategies derived from an OMM-based RCA could lead to safer work environments and create a positive social change for employees of industrial organizations.