An Approach to Description of Accident Causation and Identification of Preconditions for Effective Risk Management

The ultimate objectives of the present study is to better understand the mechanisms of major accidents in the present dynamic and technological society. From this understanding, guides to improved strategies for industrial risk management is sought. In this approach, risk management is considered a control problem, that can only be discussed in depth when considering carefully the decision making involved in the normal operation of the hazardous processes posing potential for major accidents. A key problem in this context is the information flow among the decision makers at all levels of society: How are objectives, values, and operational targets communicated? How are the boundaries of safe operation identified and communicated? How is operation monitored through routine operational reports and reports from incidents and accidents? What do guidelines look like when an improved, consistent "safety control" must be established from a control theory point of view? The report discusses these issues on the basis of the present rapid evolution of new cognitive approaches to the study of decision making in action and dynamic, learning organizations, and the rapid change of modern information technology.