• Published: May 2021
• REF/ISBN: 9781787252141
• Edition: 1st
• Status: Current

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This report has been split into the following three sections:

Part 1: Cultural precursors to major events: Good practice expectations

Part 1 reports on findings from a deeper analysis of the causative, organisational and cultural precursors for a sample of 12 major events drawn from a range of industry sectors. 10 'themes' are identified that provide a means of classifying these important precursors to
the events. These are:

1. Leadership.
2. Safety culture.
3. The business environment – Commercial pressures.
4. Effective communication.
5. The safety management systems.
6. Risk assessment and management.
7. Developing and maintaining a learning organisation.
8. Maintaining competence.
9. Management of contractors – The supply chain.
10. Oversight and scrutiny (O&S).

Part 2: Organisational learning and the design of evidence-based interventions

Part 2 provides a critical commentary on contemporary theory and practice in addressing behavioural and cultural elements. A  core theme relates to the role of evidence within the related domains of:

• identifying structural, organisational and socio-technical weakness;
• setting priorities for intervention to enhance resilience;
• intervention options appraisal – theories of change and what works, and
• intervention design and delivery – intervention logic – how will 'it' work and impact
  evaluation.

Options are also discussed for data gathering, and the relative strengths and limitations of lag and lead indicators and their potential contribution to identifying priorities for informing managerial/safety function thinking over intervention and improvement.

Part 3: System dynamics modelling

Part 3 presents the argument that the ability of an organisation to learn from past events and proactively improve resilience is often constrained by simplifications made in the way event causality is conceived and modelled. It explores the scope for using system dynamics modelling as a means of identifying, articulating and making transparent, vulnerabilities within complex socio-technical systems that balance some of the shortfalls of other existing approaches. CLDs provide an intuitive graphical representation of how variables interrelate and align. Modelling is relevant to a range of complementary risk management domains, including:

• representation of incident causality;
• testing the resilience of established safety systems and control measures, and
• proof-testing the logic of change/improvement intervention ideas.