Journal ArticleDOI
Coordinability and consistency in accident causation and prevention: formal system theoretic concepts for safety in multilevel systems
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TLDR
This work introduces the notions of coordinability and consistency from the hierarchical and multilevel systems theory literature and investigates the applicability and the importance of these concepts to accident causation and safety.Abstract:
Although a "system approach" to accidents in sociotechnical systems has been frequently advocated, formal system theoretic concepts remain absent in the literature on accident analysis and system safety. To address this gap, we introduce the notions of coordinability and consistency from the hierarchical and multilevel systems theory literature. We then investigate the applicability and the importance of these concepts to accident causation and safety. Using illustrative examples, including the worst disaster in aviation history, and recent incidents in the United States of aircraft clipping each other on the tarmac, we propose that the lack of coordinability is a fundamental failure mechanism causing or contributing to accidents in multilevel systems. We make a similar case for the lack of consistency. Coordinability and consistency become ingredients for accident prevention, and their absence fundamental failure mechanisms that can lead to system accidents. Finally, using the concepts introduced in this work, we identify several venues for further research, including the development of a theory of coordination in multilevel systems, the investigation of potential synergies between coordinability, consistency, and the high reliability organizations paradigm, and the possibility of reframing the view that "sloppy management is the root cause of many industrial accidents" as one of lack of coordinability and/or consistency between management and operations. By introducing and expanding on the concepts of coordinability and consistency, we hope to contribute to the thinking about, and the to language of, accident causation, and prevention and to add to the intellectual toolkit of safety professionals and academics.read more
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Journal ArticleDOI
Challenges in the vulnerability and risk analysis of critical infrastructures
Enrico Zio,Enrico Zio +1 more
TL;DR: The integration of different types of analyses and methods of system modeling is put forward for capturing the inherent structural and dynamic complexities of critical infrastructures and eventually evaluating their vulnerability and risk characteristics, so that decisions on protections and resilience actions can be taken with the required confidence.
Journal ArticleDOI
Near-miss management systems and observability-in-depth: Handling safety incidents and accident precursors in light of safety principles
TL;DR: In this article, the authors present an updated review and synthesis of key ideas and challenges of NMS, and examine important synergies between fundamental safety principles adopted in risk management, including defense and observability-in-depth, and NMS.
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Texas City refinery accident: Case study in breakdown of defense-in-depth and violation of the safety–diagnosability principle in design
TL;DR: In this paper, the authors propose a general safety-diagnosability principle for supporting accident prevention, which requires that all safety-degrading events or states that defense-in-depth is meant to protect against be diagnosable, and that breaches of safety barriers be unambiguously monitored and reported.
Texas City refinery accident: Case study in breakdown of defense-in-depth and violation of the safety-diagnosability principle in design q
TL;DR: A general safety–diagnosability principle is proposed for supporting accident prevention, which requires that all safety-degrading events or states that defense-in-depth is meant to protect against be diagnosable, and that breaches of safety barriers be unambiguously monitored and reported.
Journal ArticleDOI
Critical Infrastructures Vulnerability and Risk Analysis
TL;DR: The concepts of vulnerability, risk and resilience are discussed in details and analyzed with respect to their characterization in critical infrastructures (CIs) and the challenges therein.
References
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