Coordinability and consistency in accident causation and prevention
Formal system theoretic concepts for safety in multilevel systems
Although a "system approach" to accidents in sociotechnical systems has been frequently advocated, formal system theoretic concepts remain absent in the literature on accident analysis and system safety. To address this gap, we introduce the notions of coordinability and consistency from the hierarchical and multilevel systems theory literature. We then investigate the applicability and the importance of these concepts to accident causation and safety...Coordinability and consistency become ingredients for accident prevention, and their absence fundamental failure mechanisms that can lead to system accidents. Finally, using the concepts introduced in this work, we identify several venues for further research, including the development of a theory of coordination in multilevel systems, the investigation of potential synergies between coordinability, consistency, and the high reliability organizations paradigm, and the possibility of reframing the view that "sloppy management is the root cause of many industrial accidents" as one of lack of coordinability and/or consistency between management and operations.
Source : Cowlagi RV, Saleh JH. Risk Anal. Vol. X, no. X, 2012, ePub: http://ares.lids.mit.edu/~rcowlagi/papers/RA12-Coordinability.pdf