When Organisations Fail: New Thinking on Disasters

Disasters are often tragic outcomes of high-risk technologies such as mines. In Australia, more mines are being developed every day, and the risk of disasters is ever increasing. No matter how effective our conventional safety devices are, there is a form of accident that is inevitable. These relate to accidents that result from æinteracting failuresÆ in a way that could not be foreseen by the designers. In so-called ætightly coupled production systemsÆ (processes that happen very fast, such as on a high producing mine) the risk is even higher and our risk controls mostly introduce some sort of a technological fix. While we are at the one hand attempting to control the risk, we are also introducing another level of complexity. Are we really controlling the risk? This is one of the fundamental questions that will be addressed in this paper: Do we have the ability within the mining industry and other industries to effectively prevent these catastrophes, or are we, on the contrary, faced with an increasing risk as a result of increasing complexities of our technology, management systems and practices. This paper will contend that perceived improvement in risk control is an illusion of activity, and that the likelihood of mining catastrophes may be exponentially increasing. Although the paper focuses on the mining sector many aspects may be applicable across a range of industries. This paper will further contend that we are applying the right solutions to the wrong problems. Our focus is technological and procedural, while our problem is one of production cultures ripe for error and failure.