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Proactive assessment of breaches of safety constraints and causal organizational breakdowns in complex systems: A joint STAMP–VSM framework for safety assessment

Kazaras Konstantinos, Kirytopoulos Konstantinos, Kontogiannis Thomas

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Περίληψη

The evolution of accident causation models indicates a shift from the representation of sequences of events to the dynamic analysis of the whole system (i.e. systemic approaches). Respectively, the evolution of safety assessment methods reveals a gradual shift from a search for single immediate causes to a recognition of multiple causes such as organizational and management breakdowns. Following this line of thought, system and control-theoretic accident analysis methods (i.e. STAMP) have been proposed that view safety as a control problem in enforcing safety constraints. In parallel, other models with an organizational cybernetic perspective (i.e. the Viable System Model) have revealed system vulnerabilities and degradations that may lead to loss of control or flaws in control. This paper attempts to bridge the gap between these two parallel trends in systemic safety approaches. In particular, the STAMP model has been enhanced with patterns of organizational breakdowns that may account for the observed flaws in enforcing constraints. As a result, a STAMP–VSM joint framework has been proposed that helps to identify control flaws and trace their distant causes into the breakdown of organizational processes. To illustrate the applicability of this framework in proactive safety assessments, a case study of maintaining safety in a road tunnel organization is thoroughly presented.

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