Proactive Risk Management in a Dynamic Society
Jens Rasmussen and Inge Svedung
Swedish Rescue Services Agency, Karlstad, Sweden, 2000
A free electronic version of the report can be downloaded from the following URL:
The term socio-technical system is widely used in the literature to describe systems that include technical components, hardware and software, as well as operational processes, and the people who use and interact with the systems. In addition, the term encompasses the organisational policies and rules that govern the systems' use and the regularity and legal context within which they are shaped.
It is not difficult to discern these influences in the reports of major incident investigations. There will be references to equipment, operators, human factors, operational and maintenance procedures, organisational policy, management decisions, regulators, government policy and the legal system.
Rasmussen and Svedung observe that the daily work of the actors behind these influences is not linked in any apparent functional manner, but when an accident is analysed they are drawn together in a coupled pattern and may be shown to shape the causal path leading to the accident.
Two key concepts are stressed in the title, namely proactive and dynamic. Dynamic refers to the constant changes experienced by all domains at the operational level of society as a result of competitive pressures, cost reduction exercises, changes in ownership, changing political priorities, new regulations, evolving technology etc. All this leads to dynamic interactions in the influence nexus. Proactive refrs to the closed loop nature of the interactions between the decision makers and actors involved in a system.
This report presents a framework for analysing domain specific systems, identifying the significant risks they need to control, identifying the actors and decision makers involved in their operation, and the information flows that pass between them. It requires that the safe operational envelopes of these systems are well understood and that safety is measured and communicated in terms of these envelopes and achieved through constraints on decision makers. I thoroughly recommend this report to safety professionals, as it has been very influential in recent safety research. However, it is not a breezy read and warrants careful and reflective study.
Roger Shaw MIRM, Head of Risk Management, City & Hackney Teaching Primary Care Trust