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Coordinability and Consistency in Accident Causation and Prevention: Formal System Theoretic Concepts for Safety in Multilevel Systems

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  • Raghvendra V. Cowlagi
  • Joseph H. Saleh

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.

Suggested Citation

  • Raghvendra V. Cowlagi & Joseph H. Saleh, 2013. "Coordinability and Consistency in Accident Causation and Prevention: Formal System Theoretic Concepts for Safety in Multilevel Systems," Risk Analysis, John Wiley & Sons, vol. 33(3), pages 420-433, March.
  • Handle: RePEc:wly:riskan:v:33:y:2013:i:3:p:420-433
    DOI: 10.1111/j.1539-6924.2012.01886.x
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    References listed on IDEAS

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    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.
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    4. Paul R. Kleindorfer & James C. Belke & Michael R. Elliott & Kiwan Lee & Robert A. Lowe & Harold I. Feldman, 2003. "Accident Epidemiology and the U.S. Chemical Industry: Accident History and Worst‐Case Data from RMP*Info," Risk Analysis, John Wiley & Sons, vol. 23(5), pages 865-881, October.
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    Cited by:

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    2. J. S. Busby & B. Green & D. Hutchison, 2017. "Analysis of Affordance, Time, and Adaptation in the Assessment of Industrial Control System Cybersecurity Risk," Risk Analysis, John Wiley & Sons, vol. 37(7), pages 1298-1314, July.
    3. Lai, Hsueh-Yi & Chen, Chun-Hsien & Zheng, Pai & Khoo, Li Pheng, 2020. "Investigating the evolving context of an unstable approach in aviation from mental model disconnects with an agent-based model," Reliability Engineering and System Safety, Elsevier, vol. 193(C).
    4. Lai, Hsueh-Yi & Chen, Chun-Hsien & Khoo, Li-Pheng & Zheng, Pai, 2019. "Unstable approach in aviation: Mental model disconnects between pilots and air traffic controllers and interaction conflicts," Reliability Engineering and System Safety, Elsevier, vol. 185(C), pages 383-391.
    5. Lai, Hsueh-Yi & Chen, Chun-Hsien & Zheng, Pai & Khoo, Li Pheng, 2019. "Towards better information transparency in the air traffic landing system: A novel agent-based model with implicit interactions," Reliability Engineering and System Safety, Elsevier, vol. 191(C).
    6. Rui Huang & Hui Liu & Hongliang Ma & Yujie Qiang & Kai Pan & Xiaoqing Gou & Xin Wang & Dong Ye & Haining Wang & Adam Glowacz, 2022. "Accident Prevention Analysis: Exploring the Intellectual Structure of a Research Field," Sustainability, MDPI, vol. 14(14), pages 1-26, July.

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