Man-made disasters: why technology and organizations (sometimes) fail

摘要

The paper presents a systems view of the organizational preconditions to technological accidents and disasters, and in particular the seminal "Man-made Disasters model" proposed by the late Professor Barry Turner. Events such as Chernobyl, the Challenger and Bhopal have highlighted the fact that in seeking the causes of many modern large-scale accidents we must now consider as key the interaction between technology and organizational failings. Such so-called 'organizational accidents' stem from an incubation of latent errors and events which are at odds with the culturally taken for granted, accompanied by a collective failure of organizational intelligence. Theoretical models have also moved on now, from purely post hoc descriptions of accidents and their causes, in the attempt to specify 'safe' cultures and 'high-reliability' organizations. Recent research, however, has shown us that while effective learning about hazards is a common assumption of such attempts, organizations can be very resistant to learning the full lessons from past incidents and mistakes. Two common barriers to learning from disasters are: (t) information difficulties; and (2) blame and organizational politics. Ways of addressing these barriers are discussed, and the example of aviation learning systems, as an illustration of institutional self-design, is outlined.