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

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  • 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
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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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    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).

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