Understanding Organisational & Cultural Precursors to Events

Reviewing the collective findings from investigations into a range of major events in high hazard industries has led to the conclusion that there is a need to develop greater resilience to their organisational and cultural causes. This requires more rigorous methods for identifying disaster precursors and also to support intervention design. A study of the organisational and cultural precursors relating to twelve major events across several high hazard industries revealed many shared disaster precursors in areas such as leadership, operational attitudes and behaviours, communication, risk analysis, learning and, oversight and scrutiny. This has enabled statements of good practice ('expectations') to be developed, together with draft 'penetrating' question sets that can be used by industry and regulators to profile organisational risk management resilience and thereby drive organisational learning. The research shows that the processes of incubation and evolution of disaster events can be complex, and to exercise control therefore requires the development of more sophisticated 'tools' than are currently available. It has revealed repeating patterns of failure and the importance of psychological and behavioural factors which have led to poor decision making. Causal loop modelling is being used to capture these patterns and factors to facilitate the design of more informed interventions. The emerging issues and new approaches being developed are discussed and examples given.