IDEAS home Printed from https://ideas.repec.org/a/eee/reensy/v99y2012icp193-208.html
   My bibliography  Save this article

A systemic analysis of patterns of organizational breakdowns in accidents: A case from Helicopter Emergency Medical Service (HEMS) operations

Author

Listed:
  • Kontogiannis, Tom
  • Malakis, Stathis

Abstract

In recent years, many accident models and techniques have shifted their focus from shortfalls in the actions of practitioners to systemic causes in the organization. Accident investigation techniques (e.g., STAMP) have been developed that looked into the flaws of control processes in the organization. Organizational models have looked into general patterns of breakdown related to structural vulnerabilities and gradual degradation of performance. Although some degree of cross-fertilization has been developed between these two trends, safety analysts are left on their own to integrate this gap between control flaws and patterns of organizational breakdown in accident investigation. This article attempts to elaborate the control dynamics of the Systems Theoretic Accident Model and Process (STAMP) technique on the basis of a theoretical model of organizational viability (i.e., the Viable Systems Model). The joint STAMP–VSM framework is applied to an accident from a Helicopter Emergency Medical Service (HEMS) organization to help analysts progress from the analysis of control flaws to the underlying patterns of breakdown. The joint framework may help analysts to rethink the safety organization, model new information loops and constraints, look at the adaptation and steering functions of the organization and finally, develop high leverage interventions.

Suggested Citation

  • Kontogiannis, Tom & Malakis, Stathis, 2012. "A systemic analysis of patterns of organizational breakdowns in accidents: A case from Helicopter Emergency Medical Service (HEMS) operations," Reliability Engineering and System Safety, Elsevier, vol. 99(C), pages 193-208.
    • Handle: RePEc:eee:reensy:v:99:y:2012:i:c:p:193-208
    DOI: 10.1016/j.ress.2011.07.009
    as

    Download full text from publisher

    File URL: http://www.sciencedirect.com/science/article/pii/S0951832011001517
    Download Restriction: Full text for ScienceDirect subscribers only
    File URL: https://libkey.io/10.1016/j.ress.2011.07.009?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    As the access to this document is restricted, you may want to search for a different version of it.

    References listed on IDEAS

    as
    1. Saleh, J.H. & Marais, K.B. & Bakolas, E. & Cowlagi, R.V., 2010. "Highlights from the literature on accident causation and system safety: Review of major ideas, recent contributions, and challenges," Reliability Engineering and System Safety, Elsevier, vol. 95(11), pages 1105-1116.
    2. Furniss, Dominic & Back, Jonathan & Blandford, Ann & Hildebrandt, Michael & Broberg, Helena, 2011. "A resilience markers framework for small teams," Reliability Engineering and System Safety, Elsevier, vol. 96(1), pages 2-10.
    3. Gomes, Jose O. & Woods, David D. & Carvalho, Paulo V.R. & Huber, Gilbert J. & Borges, Marcos R.S., 2009. "Resilience and brittleness in the offshore helicopter transportation system: The identification of constraints and sacrifice decisions in pilots’ work," Reliability Engineering and System Safety, Elsevier, vol. 94(2), pages 311-319.
    4. Marais, K.B. & Saleh, J.H., 2008. "Conceptualizing and communicating organizational risk dynamics in the thoroughness–efficiency space," Reliability Engineering and System Safety, Elsevier, vol. 93(11), pages 1710-1719.
    5. J. S. Busby, 2006. "Failure to Mobilize in Reliability‐Seeking Organizations: Two Cases from the UK Railway," Journal of Management Studies, Wiley Blackwell, vol. 43(6), pages 1375-1393, September.
    Full references (including those not matched with items on IDEAS)

    Citations

    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.
    as


    Cited by:

    1. Read, G.J.M. & Naweed, A. & Salmon, P.M., 2019. "Complexity on the rails: A systems-based approach to understanding safety management in rail transport," Reliability Engineering and System Safety, Elsevier, vol. 188(C), pages 352-365.
    2. Mahdieh Delikhoon & Esmaeil Zarei & Osiris Valdez Banda & Mohammad Faridan & Ehsanollah Habibi, 2022. "Systems Thinking Accident Analysis Models: A Systematic Review for Sustainable Safety Management," Sustainability, MDPI, vol. 14(10), pages 1-28, May.
    3. Ferjencik, Milos, 2014. "IPICA_Lite—Improvements to root cause analysis," Reliability Engineering and System Safety, Elsevier, vol. 131(C), pages 1-13.
    4. Rose, Rodrigo L. & Mugi, Sohan R. & Saleh, Joseph Homer, 2023. "Accident investigation and lessons not learned: AcciMap analysis of successive tailings dam collapses in Brazil," Reliability Engineering and System Safety, Elsevier, vol. 236(C).

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Novak, Jeremy & Farr-Wharton, Ben & Brunetto, Yvonne & Shacklock, Kate & Brown, Kerry, 2017. "Safety outcomes for engineering asset management organizations: Old problem with new solutions?," Reliability Engineering and System Safety, Elsevier, vol. 160(C), pages 67-73.
    2. Bergström, Johan & van Winsen, Roel & Henriqson, Eder, 2015. "On the rationale of resilience in the domain of safety: A literature review," Reliability Engineering and System Safety, Elsevier, vol. 141(C), pages 131-141.
    3. Francis, Royce & Bekera, Behailu, 2014. "A metric and frameworks for resilience analysis of engineered and infrastructure systems," Reliability Engineering and System Safety, Elsevier, vol. 121(C), pages 90-103.
    4. de Carvalho, Paulo Victor Rodrigues, 2011. "The use of Functional Resonance Analysis Method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience," Reliability Engineering and System Safety, Elsevier, vol. 96(11), pages 1482-1498.
    5. Zhou, Di & Zhuang, Xiao & Zuo, Hongfu & Cai, Jing & Zhao, Xufeng & Xiang, Jiawei, 2022. "A model fusion strategy for identifying aircraft risk using CNN and Att-BiLSTM," Reliability Engineering and System Safety, Elsevier, vol. 228(C).
    6. J. S. Busby & A. M. Collins, 2014. "Organizational Sensemaking About Risk Controls: The Case of Offshore Hydrocarbons Production," Risk Analysis, John Wiley & Sons, vol. 34(9), pages 1738-1752, September.
    7. Wu, Chao & Huang, Lang, 2019. "A new accident causation model based on information flow and its application in Tianjin Port fire and explosion accident," Reliability Engineering and System Safety, Elsevier, vol. 182(C), pages 73-85.
    8. Ofori, Elvis Kwame & Aram, Simon Appah & Saalidong, Benjamin M. & Gyimah, Justice & Niyonzima, Patrick & Mintah, Clement & Ahakwa, Isaac, 2023. "Exploring new antecedent metrics for safety performance in Ghana’s oil and gas industry using partial least squares structural equation modelling (PLS-SEM)," Resources Policy, Elsevier, vol. 81(C).
    9. Favarò, Francesca M. & Saleh, Joseph H., 2016. "Toward risk assessment 2.0: Safety supervisory control and model-based hazard monitoring for risk-informed safety interventions," Reliability Engineering and System Safety, Elsevier, vol. 152(C), pages 316-330.
    10. Foreman, Veronica L. & Favaró, Francesca M. & Saleh, Joseph H. & Johnson, Christopher W., 2015. "Software in military aviation and drone mishaps: Analysis and recommendations for the investigation process," Reliability Engineering and System Safety, Elsevier, vol. 137(C), pages 101-111.
    11. Seyed Mohammad Asadzadeh & Hadi Maleki & Mehrab Tanhaeean, 0. "A resilience engineering-based approach to improving service reliability in maintenance organizations," International Journal of System Assurance Engineering and Management, Springer;The Society for Reliability, Engineering Quality and Operations Management (SREQOM),India, and Division of Operation and Maintenance, Lulea University of Technology, Sweden, vol. 0, pages 1-14.
    12. James H. Lambert & Jeffrey M. Keisler & William E. Wheeler & Zachary A. Collier & Igor Linkov, 2013. "Multiscale approach to the security of hardware supply chains for energy systems," Environment Systems and Decisions, Springer, vol. 33(3), pages 326-334, September.
    13. Volker H. Hoffmann & Thomas Trautmann & Jens Hamprecht, 2009. "Regulatory Uncertainty: A Reason to Postpone Investments? Not Necessarily," Journal of Management Studies, Wiley Blackwell, vol. 46(7), pages 1227-1253, November.
    14. Park, Jinkyun & Jung, Wondea, 2015. "A systematic framework to investigate the coverage of abnormal operating procedures in nuclear power plants," Reliability Engineering and System Safety, Elsevier, vol. 138(C), pages 21-30.
    15. Tsagkas, Vassilis & Nathanael, Dimitris & Marmaras, Nicolas, 2014. "A pragmatic mapping of factors behind deviating acts in aircraft maintenance," Reliability Engineering and System Safety, Elsevier, vol. 130(C), pages 106-114.
    16. Mendes, Pietro A.S. & Hall, Jeremy & Matos, Stelvia & Silvestre, Bruno, 2014. "Reforming Brazil׳s offshore oil and gas safety regulatory framework: Lessons from Norway, the United Kingdom and the United States," Energy Policy, Elsevier, vol. 74(C), pages 443-453.
    17. Ferjencik, Milos, 2014. "IPICA_Lite—Improvements to root cause analysis," Reliability Engineering and System Safety, Elsevier, vol. 131(C), pages 1-13.
    18. Saleh, Joseph H. & Pendley, Cynthia C., 2012. "From learning from accidents to teaching about accident causation and prevention: Multidisciplinary education and safety literacy for all engineering students," Reliability Engineering and System Safety, Elsevier, vol. 99(C), pages 105-113.
    19. Xinglong Wang & Shangfei Miao & Junqing Tang, 2020. "Vulnerability and Resilience Analysis of the Air Traffic Control Sector Network in China," Sustainability, MDPI, vol. 12(9), pages 1-18, May.
    20. Varajão, João & Fernandes, Gabriela & Amaral, António & Gonçalves, A. Manuela, 2021. "Team Resilience Model: An Empirical Examination of Information Systems Projects," Reliability Engineering and System Safety, Elsevier, vol. 206(C).

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:reensy:v:99:y:2012:i:c:p:193-208. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu (email available below). General contact details of provider: https://www.journals.elsevier.com/reliability-engineering-and-system-safety .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.