Systems thinking, culture of reliability and safety

摘要

The paper reflects upon the intellectual contribution of both David Blockley and the late Barry Turner to contemporary thinking about organisational accidents and safety cultures in hazardous systems. When they first worked together in the 1980s, events such as the Chernobyl and Challenger accidents highlighted the fact that in seeking the causes of many modern large-scale accidents we must now consider the interaction between technology and organisational failings. Theoretical models also moved on at that time from descriptions of accidents and their causes, in an attempt to specify 'safe' cultures and 'high-reliability' organisations. Recent research has shown us that while effective learning about hazards is a common assumption of such attempts, organisations can still be very resistant to learn the full lessons from past incidents and mistakes. This paper discusses the ways of addressing barriers to learning in high-risk socio-technical systems.