Accidents organizational factors

The first area focuses on the cultural and organizational factors that will have a major influence on the effectiveness of a human error data collection system and how well the information derived from such a system is translated into successful error reduction strategies. Regardless of how effectively the technical issues are dealt with, the system will not be successful imless there is a culture in the organization which provides support for the data gathering process. No data collection system aimed at identifying human error causes of accidents will be workable without the active cooperation of the workforce. 

Chapter 11 describes a way to perform better analyses of anomalies, incidents, and accidents. But having a process is not enough the process must be embedded in an organizational structure that allows the successful exploitation of that process. Two important organizational factors will impact the successful use of CAST training and follow-up. 

In some industries, the safety control structure is called the safety management system (SMS). In civil aviation, ICAO (International Civil Aviation Authority) has created standards and recommended practices for safety management systems and individual countries have strongly recommended or required certified air carriers to establish such systems in order to control organizational factors that contribute to accidents. 

Stringfellow, Margaret. Human and Organizational Factors in Accidents. Ph.D. Dissertation, Aeronautics and Astronautics, MIT, 2010. 

Accident reporting deficiencies related to human and organizational factors in engine room fires on board ships... 

This paper is based on a recent study (Ghirxi, 2008) where 41 accident reports of engine room fires were reviewed. Although this review reveals that especially organizational factors were not considered in... 

One of the initial assumptions was that especially in accidents which did not result in a total loss, organizational factors should clearly be visible. 56% of... 

Another assumption was that the ISM Code introduction in 1998 and 2002 (apphcable entry into force date depended on the type of ship) might eventually also show an effect regarding organizational factors identified during accident investigations. This, at least, was the objective of the ISM Code introduction. 

One aspect could relate to the accident reports. Is it possible to address organizational factors identified in accident investigation in a review involving 41 accident investigation reports ... 

Engine-room and machinery space fires and explosions might represent an accident category that is less affected by organizational factors, and... 

One possible explanation for the large number of unsafe acts and preconditions for unsafe acts mentioned earher was that machinery space fires and explosions could be less likely to be affected by organizational factors. This explanation can be dismissed easily. First, similar studies with HFACS on other accident categories in other industries revealed similar problems (Thaden et al., 2004). At the same time HFACS is considered as a method that can provide appropriate results, meaning that the method itself does not lead to an overrepresentation of unsafe acts and preconditions of unsafe acts alone. 

Despite the initial expectation that this would lead to a number of organizational factors identified during the accident investigation the reports focused mainly on rmsafe acts and preconditions for rmsafe acts and ignored organizational factors to a large degree. 

The discussion suggested that the current discussion about epidemiological and systemic models might not be the reason why organizational factors are underrepresented. The setup and the mandate of maritime accident investigation may cause the focus of unsafe acts and preconditions for rmsafe acts only. 

The results of these 41 accident reports might be symptomatic of maritime accident investigation. Accident investigation bodies apparently need time, resources, and expertise in order to address organizational factors. This includes a legal mandate to do this. 

Proper designing of the alarm system, as the layer of protection in hazardous plant, will contribute to reducing the hmnan error probability (HEP), what will result in decreasing the risk of potential accidents. The human and organizational factors should be also care fully considered in designing and operating of protections to eliminate or reduce probability of latent and active failures (Kosmowski 2007). 

As it was mentioned the operator performance is influenced by the human and organizational factors. If they are properly shaped can contribute significantly to mitigating the human error probability (HEP) and failure events that result in decreasing the risk related to accidents scenarios identified in the process of risk analysis. 

Thus, the layers of protection designing process should include appropriate human reliability analysis (HRA) method, with emphasis on human and organizational factors identified for particular accident scenario considered. A numerous studies have been performed in that context and a number of methods exist (Humphreys 1988). 

Nonfunctional If the persons or objects in the energy path were not there as a necessary part of the system, they are nonfunctional. This class generally includes visitors, passers-by, the great American public, intruders, and perhaps even organizational members with no requirement to be at the accident location when the accident occurred. Factors to be evaluated include... 

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