The Importance of Misalignment to Reduce Risk and Prevent Disasters

Abstract

Large incidents are a combination of different factors. Any of those factors on their own would not have produced the incident, but together can be catastrophic. This unfortunate alignment is the nature of all disasters. Understanding how each piece came together to produce that incident provides important insight for reducing risk and preventing future incidents from occurring. Some organizations within the energy, aviation and healthcare industries cite James Reason’s Swiss cheese model of accident causation to explain this confluence of events. The holes in each slice align just right for the incident to occur. Moving just one of the slices can prevent a negative outcome. If more than one slice is misaligned, the risk can be made even lower. This is also known as defense in depth and layers of protection—approaches used across high-risk industries. The straight-line slices of cheese overlook the important interconnections within complex issues. An incident consists of multiple cause-and-effect relationships that all come together in a particular way. Digging into these causes provides opportunities to misalign an incident, reducing the risk of the system in the future. Highly reliable organizations dissect their operations to pinpoint where simple verifications and checks can make the likelihood of an incident significantly lower. This presentation uses a few historical disasters, including the 2005 Texas City refinery explosion, to explain how a complex incident can be analyzed starting with just a few basic cause-and-effect relationships. That simple analysis can then be expanded into a much more detailed explanation revealing how simple miscommunications like shift change, were causally related to the disaster. Changing one item would have changed that incident. Improving the way people communicate details within an incident improves the way they mitigate risk and prevent incidents going forward.