Notes:
Almost all SPADs caused by driver error. Need to look beyond the driver’s error which is the immediate causes of a SPAD to the organisational factors that influence these errors. After all, drivers cannot be expected to be completely reliable.
Several researchers have argued that the causes of accidents lie in the organisation. Reason describes currents (flows) in the safety space: following a long period of safety procedural and organisational safeguards degrade and the organisation drifts to a state of increased vulnerability. An accidents initiates an effort to improve safety procedures increasing resistance to future accidents.
Rasmussen describes safety as a dynamic non-event. A non-event because, hopefully there are no accidents. Dynamic because the organisation and the behaviour of people in it adapts to changing pressures. In particular people are subject to conflicting pressures – safety, production efficiency, reducing of effort – and they may be unaware that behaviour changes by different people in a system are gradually eroding safety margin.
Central to our work is the idea the organisational accident concept is relevant to SPAD incidents. What is the evidence for this?