The God’s eye view on systems
The God's eye view on systems
We are living in an increasingly complex world. State of the art research by Nancy Levenson and John Thomas, shows that today’s causality models used for accident investigations are becoming outdated. However, the view that accidents have a single root cause, in a linear sequence of events, still prevails today. While these models may be of use at a smaller scale for simpler systems, when we take a “God’s eye view” it becomes apparent that a new paradigm and model is needed “in the way we engineer and operate the types of systems and hazards we are dealing with today” (Levenson, 2011). The Systems Theoretic Accident Model and Processes (STAMP) is one such newer model.
History shows that accidents are not the result of unpredictable random events, but rather the accumulation of errors and questionable decisions, often related to systems complexity and the interaction of its components. Accidents like the one on board the offshore platform Piper Alpha in July 1988 or the Bourbon Dolphon vessel in April 2007, illustrate the importance of understanding system complexity. The Piper Alfa, caused by a massive fire was “rooted in the organization, its structure, procedures, and culture.” (PatC-Cornell, 1993). The case of the Bourbon Dolphin, which sunk, investigators found that there were “…defects in the implementation of the safety management system on board. This concerns primarily defects in the preparation of risk assessments, which did not cover hazards to which the vessel could be exposed. Nor did the company’s internal control manage to detect the fact that no protection against all identified risks had been erected on board” (NOU 2008).
This begs the question: How can we create a safety standard to manage an ever-increasing systems complexity? While there are models that provide an excellent framework, like the STAMP model, continued research is needed in order to cope with systems complexity and increase systems resilience.
Engineering a Safer World, by Nancy G. Leveson, 2011
Elisabeth PatC-Cornell (1993)
Risk analysis, Vol. 13, No. 2, 1993 , Learning from the Piper Alpha Accident: A Postmortem Analysis of Technical and Organizational Factors
The Loss of the “Bourbon Dolphin” on 12 April 2007- Official Norwegian Reports 2008: 8