Credits to
Maurizio Catino

Errors and disasters in complex systems

Between an accusatory paradigm, based on individual blame, and an organizational, functional approach

Issue 2/2020

Abstract. Why do accidents happen in organizations? In complex organizations, the simple punishment or even removal of the person allegedly responsible for an accident without an evaluation of the critical aspects of the system favors the repetition of errors, even by other actors. A different approach is needed, which not only focuses on human failure and blame culture, but on the different levels of organizational failure and that is ultimately aimed at improving safety conditions. After presenting and discussing the most relevant theories on the etiology of accidents in complex systems, in this article we will compare two different approaches: an individual blame logic, aimed at identifying individual human failures and responsibilities; and an organizational functional logic, aimed at identifying and removing the factors that favored the occurrence of the errors.


SUMMARY: 1. Accident prediction and avoidance in complex systems. The Normal Accidents Theory, and its limits. – 2. The causes of accidents (between person and system). – 2.1. The theory of organizational error. – 2.2. The theory of “epistemic accidents”. – 3. Accidents in complex systems, and approaches to the error. – 3.1. The individual blame logic. – 3.2. The organizational functional logic. – 4. Short final remarks.


To read the Reflection, click on “open file”.


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