6. Organisational risk model


Risk management of an organisation is crucial and challenging task. Coordinated and smooth functioning with least conflicts amongst of all major components leads towards the accident reductions. The following two models are important to discuss in the present context:

First Model: System migration

The popular framework for modelling risk management is a system framework with two components. The first is a structural hierarchy describing the actors individuals and organisations in a system. The second considers the dynamics of the system as it migrates towards the boundary of safety. An understanding of both of these components is required to model how and why accidents occur.

(a) Actors
Socio-technical systems are designed to produce a product or service while managing risk. A socio-technical system is shown as Fig 3 and it also tries to throw light on the possible interactions amongst all players. Activities of the individual staff members who interact directly with the process being controlled (e.g., control room operators, SOPs, etc.) are at the Staff level. Factors at the Management level are related to supervision of operational staff and directions received due to adaptations of company policies. Company-level factors include the activities of the company as a whole including the national and global forces responsible for quality, environmental, and safety issues. The next level represents the activities of the regulators or and professional associations or and ISOs directives that are responsible for constraining the activities of companies in that particular sector. Professional directions in this context are those that exert regulatory authority over the profession, such as the OSHAS 18001 or ISO 14001. Factors at the Government level are related to the activities of government, both public servants and elected officials, who are responsible for setting public policy.

When a system functions, decisions at higher levels of the system propagate down the hierarchy. Simultaneously, information about the current state of affairs should percolate up the hierarchy. Two-way flows of information, direction and feedback, are critical to the successful functioning of the system. If instructions from above are not formulated or carried out at the lower levels, system has no coordination and will not be protected. If information from below is not collected or conveyed to decision makers at higher levels, decisions cannot reflect the available capacity and limitations of the system or the constraints facing the system. The result is that the system can become unstable and start to lose control of the hazardous process that it is intended to control. From this perspective, safety can be viewed as an emergent product of a complex socio-technical system.

Threats to safety usually result from a loss of control caused by a lack of vertical integration, or mismatches between levels of a complex socio-technical system, not just from deficiencies at any one level alone. All layers play critical, albeit different, roles in maintaining safety. A lack of vertical integration is frequently caused, in part, by a lack of feedback between levels of a complex system. Actors at each level cannot see how their decisions interact with those made by actors at other levels, so the threats to safety are not obvious before an accident occurs because no one has a global view of the entire system.

(b) Dynamics
The second component of the framework, shown in Figure 4, considers the dynamic forces that can cause a complex socio-technical system to modify its structure and behaviour over time. Financial pressures that result in a cost gradient push the people in the system to reduce costs. Psychological pressures result in an effort gradient pushing people in the system to work in a more mentally or physically efficient manner. When all appears well and there are no accidents, the effort gradient will be viewed as positive, encouraging people to seek out new, better ways of getting the job done. This process of trial and innovation can be particularly important when people are being required to take on more responsibilities with fewer resources.

As a result of cost and effort gradients, work practices will be subject to an exploratory but systematic change over time. Financial and psychological forces inevitably lead to people finding the most economic ways of performing their job. Moreover, the modification of work practices can occur at several levels of a complex socio-technical system simultaneously. Over time, this migration causes people to cross the official boundary of work practices, shown on the near left in Figure 4a-4b. People are forced to deviate from procedures and cut corners because they are responding to requests or demands to be more cost-effective. As a result, the system's defences-in-depth degrade and erode gradually over time, not all at once. process of trial and innovation can be particularly important when people are being required to take on more responsibilities with fewer resources.

As a result of cost and effort gradients, work practices will be subject to an exploratory but systematic change over time. Financial and psychological forces inevitably lead to people finding the most economic ways of performing their job. Moreover, the modification of work practices can occur at several levels of a complex socio-technical system simultaneously. Over time, this migration causes people to cross the official boundary of work practices, shown on the near left in Figure 4a-4b. People are forced to deviate from procedures and cut corners because they are responding to requests or demands to be more cost-effective. As a result, the system's defences-in-depth degrade and erode gradually over time, not all at once.

Figure 4a

One might think that a lack of procedural compliance and the resulting degradation in safety would raise an immediate warning flag, but this does not happen for two reasons. First, the migration in work practices is required to get the job done, given the stresses that the system is undergoing. That is why "work to rule" campaigns can cause complex socio-technical systems to come to a grinding halt. Second, the migration in work practices does not usually have any visible, immediate negative impact. The threats to safety are not obvious before an accident because the violation of procedures does not immediately lead to catastrophe. At each level in the hierarchy, people are working hard, striving to respond to cost-effectiveness measures, but they do not see how their decisions interact with those made by other actors at different levels of the system. Yet, the sum total of these uncoordinated attempts at adapting to environmental stressors is slowly but surely building the conditions for an accident.

As a result, the migration of work practices continues. People try harder and harder to work in more efficient ways, and with each new innovation, they are coming closer and closer to the real boundary of safety. The boundary, however, is usually invisible; people do not know whether the system as a whole is close to or far away from disaster. Migrations from official work practices can persist and evolve for years without mishaps until the real safety boundary is reached. After an accident, workers may wonder what happened because they did not do anything differently than they had been doing in the recent past. In other words, accidents in complex socio-technical systems do not usually occur because of an unusual action or an entirely new, one-time threat to safety. Instead, they result from a combination of a systematically induced migration in work practices and an odd event that winds up revealing the degradation in safety that had been occurring all the while.

Figure 4b

So it can be concluded that the two pressure gradients, production and effort, that push actors into higher risk levels through gradual shifts in practice. This migration, associated with adapting to circumstances, does not necessarily present actors with negative feedback immediately after each "drift". In fact, the immediate feedback may be very positive, resulting in higher production and reward but may lead to big disasters.

Socio-technical systems involved in risk management begin to be considered in their entirety, with all their hierarchical levels, going from "non-shop floor" operators to the legislators and government agencies responsible for the formulation and implementation of control policies.


Second Model

The vertical orientation model (Figure-5) was suggested to "capture the causal process of losses as a boundary condition of working under pressure and to identify sensitive parameters for controlling the behaviour of organizations and individuals". The model describes the interactions between decision-makers situated at all levels in society in their roles as risk managers. The analysis takes up again the notion of control loop discussed previously, by exploring the possibilities of failure:

  • in the design of the constraints necessary for forcing the implementation of control actions;
  • in carrying out these actions;
  • in the feedback provided after carrying out the actions.

Figure 5

The analyses include maps that show the control loops and information prescribed or proposed between the different hierarchical levels of the system and the same maps showing the local adaptations that over the time the system existed were being carried out in the components, whose purpose was to impose regulatory actions or inform management of the results of the actions carried out.

Table 1 shows the taxonomy of possible failures in the design, execution or feedback of the various loops analyzed. Using these models demands abandoning the traditional approach adopted in safety management, which is based on the structural decomposition of the system, with analyses of tasks focused on action sequence and occasional deviations, treated as human errors. In its place the behaviour-modelling mechanisms model in terms of working situation constraints, acceptable performance boundaries and subjective criteria guiding the adaptations to the changes should be adopted.


Error control mechanism in process industries

After analysing the factors for a system it is important to review the global and national initiatives. In the following paragraphs these initiatives are being described.

 

 
Locations of visitors to this page