Environmental Engineering Reference
In-Depth Information
actions or decisions have larger, combined and longer term impacts on system
properties that are missed or underappreciated.
The metaphor itself oversimplifies the situation by referring to the
organization as a whole. There is ample practical experience to show that
some parts of an organization may be safe while others may be unsafe. In
other words, parts of the organization may ‗drift' in different directions. The
safety of the organization can furthermore not be derived from a linear
combination of the parts, but rather depends on the ways in which they are
coupled and how coordination across these parts is fragmented or
synchronized This is also the reason why accidents in a very fundamental
sense are non-linear phenomena.
Finally, there are no external forces that, like the wind, push an
organization in some direction, or allow the ‗captain' to steer it clear of
danger. What happens is rather that choices and decisions made during daily
work may have long-term consequences that are not considered at the time.
There can be many reasons for this, such as the lack of proper ‗conceptual'
tools or a shortage of time.[8]
It is inevitable that organizational practices change as part of daily work,
one simple reason being that the environment is partly unpredictable,
changing, or semi-erratic. Such changes are needed either for purposes of
safety or efficiency, though mostly the latter. Indeed, the most important factor
is probably the need to gain time in order to prevent control from being lost, as
described by the efficiency thoroughness trade-off [9] . There is never enough
time to be sufficiently thorough; finishing an activity in time may be important
for other actions or events, which in turn cannot be postponed because yet
others depend on them, etc. The reality of this tight coupling is probably best
illustrated by the type of industrial action that consists in ‗working to rule.'
This also provides a powerful demonstration of how important the everyday
trade-offs and shortcuts are for the normal functioning of a system.
Changed practices to improve efficiency often have long-term
consequences that affect safety, although for one reason or another they are
disregarded when the changes are made. These consequences are usually both
latent and have latency and therefore only show themselves after a while. Drift
is therefore nothing more than an accumulated effect of latent consequences,
which in turn result from the trade-off or sacrificing decisions that are required
to keep the system running.
The purpose of this topic has been to propose resilience engineering as a
step forward from traditional safety engineering techniques [10]. Rather than
try to force adaptive processes and organizational factors into these families of
