Barry Turner: The Under-Acknowledged Safety Pioneer
Abstract
:1. Introduction
1.1. Rationale for This Retrospective
so well done that it correctly anticipated developments and conclusions that other more prominent accident researchers would subsequently lay claim to (system complexity and uncertainty, how multiple failures undermine layered safety defences, the cultural blinkers that organisations adopt), even when those who followed claimed only superficial or no knowledge of Turner’s original writings.[7] (p. 239, emphasis in original)
I can’t see any sign that he [Perrow] was aware of Barry Turner’s work … The ability of people at different sides of the world to encounter each other’s work and understand where progress has been made relies on you knowing who else is working on the same things. … a lot of the work in safety, he [Perrow] never encountered, which I don’t think is his fault. Yeah, there are a lot of people today who’ve never heard of Barry Turner. … [Perrow] independently invented a lot of foundational thinking in safety, that he wasn’t the first to think of it, but he also did it without standing on the shoulders of other people who had those same ideas.[8]
1.2. Key Aims
1.3. Outline of the Article
2. Materials, Methods and Approach
3. Central Themes in MMD and Their Background
Public inquiries into … three major disasters are examined and classified to study the conditions under which large-scale intelligence failures develop. Common causal factors are rigidities in institutional beliefs, distracting decoy phenomena, neglect of outside complaints, multiple information-handling difficulties, exacerbation of the hazards by strangers, failure to comply with regulations, and a tendency to minimize emergent danger. Such features form part of the incubation stage in a sequence of disaster development, accumulating unnoticed until a precipitating event leads to the onset of the disaster and a degree of cultural collapse. Recommendations following public inquiries are seen as part of a process of cultural readjustment after a disaster, allowing the ill-structured problem which led to the failure to be absorbed into the culture in a well-structured form. The sequence model of intelligence failure presented and the discussion of cases are intended to offer a paradigm for discussion of less tragic, but equally important organizational and interorganizational failures of foresight.[27] (p. 378)
- (1)
- a notionally “normal” starting point with culturally accepted beliefs about the world and its hazards, and associated precautionary norms that are followed through regulation and less formal practices;
- (2)
- an “incubation period” when an unnoticed set of events or chains of “discrepant” events at odds with accepted beliefs and norms about hazards develop and accumulate;
- (3)
- a “precipitating” event or incident linking with the chain of discrepant events, produces a transformation revealing the “latent structure” of the incubation period and a “gap in defences that were previously considered secure”;
- (4)
- the “onset” of a disaster or major accident follows immediately from the precipitating event, with direct and “unanticipated” consequences of the failure, and an onset of varying rate and intensity over varying scope and area;
- (5)
- rescue and salvage—rapid and ad hoc changes in understanding and a first stage adjustment to the disaster; and
- (6)
3.1. Scope, Terms, Definitions and Data
It is rare that an individual, by virtue of a single error, can create a disastrous outcome in an area formerly believed to be relatively secure. To achieve such a transformation, he or she needs the unwitting assistance offered by access to the resources and resource flows … of large organizations, and time. The three accidents discussed here had been incubating for a number of years.[27] (p. 395)
If the only cause of an incident is an inappropriate response to a recognized warning, the incident is more likely to be one which we characterize as an accident: by contrast, in a pre-disaster situation, given the typically large accumulation of predisposing factors, the nature of the last error is relatively unimportant. … The incubation network only refers to those chains of events which are discrepant, but are not perceived or are misperceived. It is meaningful to compare accidents and disasters only in terms of incubation networks ….[1] (p. 88, emphasis in original)
3.2. Incubation, Failures of Foresight, Prevention and Power
- Events unnoticed or misunderstood because of erroneous assumptions due to rigidities of belief and perception, “decoy” phenomena (focus on a problem that obscures a bigger one), and disregard of complaints from “outsiders”;
- Events unnoticed or misunderstood because of difficulties in handling information in complex situations, information difficulties and “noise”, and the involvement of “strangers” (visitors and trespassers) on sites;
- Effective violations of precautions passing unnoticed because of a cultural norm lag with existing precautions, including a failure to comply with regulations which may be unknown or out-of-date;
- Events unnoticed or misunderstood because of a reluctance to fear the worst outcome, and minimising emergent danger and not taking action when things begin to go sour [1] (pp. 99–103).
it becomes necessary, also, to start to take account of those other perennial concerns of the sociologist, the charting of the distribution of power, of the control of resources and of social reputation. … Powerful groups and organizations are able to specify the kinds of hazard that they recognize, to set out and implement the kinds of precautions which they think are necessary, and to exert their authority in intervening in areas which they regard as hazardous. … There may be confrontations between those who present an official definition of hazards and others who think that the situation is different … There is thus an overlay of differential power distributions which will affect knowledge, perceptions and expectations of accidents.[1] (pp. 124–125, 152)
3.3. Turner’s Systems Approach
“All that is required is the introduction of unintended or unforeseen variety near to the organizing centre to produce a large-scale, but orderly error which makes use of the amplifying power of any ordered organizational hierarchy. If we consider organizational hierarchies as systems set up to carry out tasks, these ordered but undesired consequences could be regarded as ‘anti-tasks’ rather than as completely random errors. Large-scale disasters need time, resources and organization if they are to occur—if the ‘anti-task’ is to be successfully executed … [such disasters are] most unlikely to be met solely as a result of a concatenation of random events”.[1] (p. 180)
3.4. Turner’s Multidisciplinarity and Optimism
it is important that we should not assess the actions of decision-makers too harshly in the light of the knowledge that hindsight gives us. … it is necessary to look at the manner in which rationality becomes established and embedded within organizational procedures and habits, and to gain an understanding of the hierarchy of decision-making within which the individual administrator finds that he has to operate.[1] (pp. 162–163 note 4, 234)
we can continue to try to improve … we are in a contingent universe, in which ultimately there are limits on our ability to reduce uncertainty, to master all of the open-ended and perverse qualities of our environment, and upon our ability to prevent disaster … We may come to realize that, even when our strategies are successful, they are still dependent upon the munificence of the environment and upon the mutability of fortune.[1] (p. 201)
4. Central Themes in NA and Their Background
to chart the world of organized systems … [this] … constitutes a theory of systems, of their potential for failure and recovery from failure, As it such, it is, I believe, unique in the literature on accidents and the literature on organizations. Perhaps the most original aspect of the analysis is that it focuses on the properties of systems themselves, rather than on the errors that owners, designers, and operators make in running them.[2] (pp. 62–63)
nuclear power plants, chemical plants, aircraft and air traffic control, ships, dams, nuclear weapons, space missions, and genetic engineering. Most of these risky enterprises have catastrophic potential … it is the possibility of managing high-risk technologies better … that motivates this inquiry. There are many improvements we can make that I will not dwell on … such as better operator training, safer designs, more quality control, and more effective regulation. … Rather, I will dwell upon characteristics of high-risk technologies that suggest that no matter how effective conventional safety devices are, there is a form of accident that is inevitable.[2] (p. 3)
The inquiry … grew into a major analysis of a number of systems. … it is relentlessly ‘structural’. … Investigating a number of these accidents, I found a common pattern. While most accidents in risky systems stemmed from a major failure that could have been prevented, a substantial minority resulted from the unexpected interaction of two or more small failures. … The unexpected and generally incomprehensible interaction of small failures was found in all the complex systems I studied in any detail, including those with catastrophic potential … The sources of failure were diverse … The resulting accidents were ‘system accidents’, arising from the ability of the system to permit the unexpected interactions of failures. … Multiple, unexpectedly interacting failures in risky systems still might not be a serious concern if operators could intervene before significant damage occurs. But there is another system characteristic to consider … if coupling is tight, none of these safeguards is available. … the environment [once incorporated in analysis provides] further insight into the problem of safe systems … If we take an industry, rather than particular organizations, as the unit of analysis, we can see the impact of the industry and its ties to society upon the organization and its problems. … [e.g.,] comparing the error-inducing marine transport system with the error-avoiding airline system … The focus was on system interactions and control, whether at the level of the operator or elites deciding what kind of risks the rest of us should run.[81] (pp. 146–149, 153, 155)
4.1. System Focus and Definitions
4.2. Complexity, Coupling, System and Component Accidents
4.3. Perrow’s Sociological Background and Method
performed a ‘hammer analysis’ … I had a primitive theory about complexity and coupling and when they handed me the transcripts I pounded them with it and broke it open … In thirty days I had produced a 45-page paper that applied the theory to Three Mile Island, to tanker collisions, aircraft failures, chemical plant explosions, and suggested why most factories would not have ‘normal accidents’ or, in a more technical term, what I called ‘system accidents’. The students at Stony Brook sent me a steady stream of material and critiqued my rough drafts and ideas.
5. Similarities and Differences between Turner’s MMD and Perrow’s NA
5.1. Similarities between MMD and NA
5.2. Differences between MMD and NA
6. Turner and Perrow after MMD and NA
6.1. Turner’s Work after 1978
we do believe that the basic theoretical model set out here remains as relevant to concerns about understanding the nature and origins of acute failures of major socio-technical systems as it did … Account is … taken in Chapter 11 of the reports of work on ‘high-reliability organizations’, of the possibility of applying notions of organizational design to the encouragement of ‘safe’ organizations and ‘safety cultures’, and the more wide-ranging issues raised by a concern with institutional design as a way forward in hazard management. … Chapter 11, together with this Preface … was written by Nick Pidgeon, working initially from various notes Barry had compiled prior to his death.[10] (p. xviii)
A simple model to understand this nonrandom error propagation requires a description of the initial system structure in social and technical terms, specifying features such as the task and sentient boundaries of subsystems. … it is possible to trace the manner in which errors contributing to major system failures initiate structured consequences … When errors or distortions of intent appear … they interact with the negentropic or ordering properties of the system in which they occur to produce a novel chain of structured consequences. They create a small initial change which, depending on the location, timing, and structure, modifies the future arrangement of events in a manner that has its own logic and order. … In most accidents, it is axiomatic that there is never merely one starting point, but that there are at least six or seven … all of which must be taken account of in understanding the resulting multiple interaction patterns. … An unintended event will trace out those aspects of the preexisting system which it does not destroy. The error and the system intervention phases start in what we have previously referred to as the ‘incubation period’ of a large-scale accident, but they continue into the ‘onset’ stage and beyond … When unforeseen events occur, their consequences are strongly constrained by preexisting technical, task, and sentient structures. When the intervention is not strong enough to disrupt the structure completely, its consequences trace out a portion of the structure. We are thus encouraged to look for regularities in the apparently unstructured events surrounding large-scale accidents or large-scale system failures, and to reduce the extent to which we automatically assume ideas of ‘randomness’ will offer us an understanding of such phenomena.[122] (pp. 437–444)
It is also possible to think of the culture of small groups of workers, of departments, of divisions and organisations as being nested successively within one another, and then to consider the organisational culture as being located within a national or international framework.[65] (p. 249)
outside the precincts of classical rational-technical organizational theory and systems analysis … from positivism … [to] new interest in methods of qualitative inquiry and analysis … [to] symbols and culture in general … shared realities … a view based upon negotiation will see a complex of subcultures and counter-cultures … separating the ‘corporate culture’ from ‘culture in work’ which workers (and mangers) weave for themselves while making sense of their experiences in the organization.[108] (pp. 83, 86–87, 90, 94)
the classificatory world view emphasizes a changing and kaleidoscopic perspective in which symbols exist within a frame, and in this perspective symbols of reversal are seen as expected and nourishing. By contrast, the instrumental world view, a more technological and purposive one, emphasizes the sequential harnessing of means to an end. The instrumental view threatens and is threatened by symbols of reversal. … Some safety specialists seem to be confident that accidents can be instrumentally eliminated from organizations, especially now that the model of accident generation has been completed by the identification by some of them of the role of ‘organization’ as the final ‘variable’ contributing to accidents. This view, however, can only be sustained by pushing the instrumental view to the centre and suppressing or eliminating the negative and the inversion. A control system is effectively a system of marks, but by reframing, by allowing the marks to migrate, other possibilities come into view. Management, including hazard management, must take an instrumental view of the world almost by definition. But unless some of the potential for reversal and transformation is recognised, managerial activities will repeatedly be threatened by apparently inexplicable and uncontrollable transformations, upsets and contingencies.[126] (p. 37)
6.2. Perrow’s Work after 1984 and Assessment of Normal Accidents
the kind of sociologist who emphasizes the overriding importance of power and interests in society, rather than the kind that emphasizes nurture, culture, or common humanity … [one who promoted better] structures … organizational forms, laws … Context shapes behavior, but the temptation to self-interested behavior is always there and must be fought.[152] (p. 92)
6.3. Similarities and Differences after Publication of MMD and NA
Only a few disasters, I believe will be exclusively due to design or human factors failures that cannot be attributed to higher level explanations. Any accidents, as opposed to disasters, can be traced to operator error … Disasters require a configuration that is more likely to be due to organizational and sociocultural factors. A few of these will be what I call ‘system accidents’, inherent in systems that are complexly interactive and also tightly coupled … The vast majority of disasters will be due to organizational, and ultimately, to sociocultural factors.[92] (p. 284)
7. Turner and Perrow: Acknowledgment and Citation
7.1. Perrow’s Knowledge of MMD
I just don’t feel that close to Barry’s work, so about all I could say would be that it was the earliest attempt to think through the matter of disasters in organizational terms, and thus very useful and insightful. To say so little would not serve much purpose. We approached disasters very differently, and indeed organizational analysis in general. Barry’s work has been strongest in the culture area, while I have been much more concerned with structure. He also had a catholic interest in disasters, whereas my concern has been quite narrow, focusing upon a small set of (very risky) systems, and even then with structural causes and little concern with the recovery phase, or even prevention. So there is not much in common.[193]
7.2. Perrow’s Citation of Turner
One might note one infrequent, but perverse, barrier to learning at this point, originally identified, I believe, by Turner (1978: 224) in Man-made Disasters, where accident investigations convert ill structured problems into well structured ones (see also Vaughan, 1994). Accident investigations are ‘left censored’ in that they examine only systems that failed, not the ones with the same characteristics that have not failed.[90] (p. 214)
Nevertheless, there is a reasonably interesting ‘schematic report analysis diagram’ that analyses the Cambrian Colliery accident of 1965, based on the work of B.A. Turner (as is a great deal of the book), a pioneer in the accident field. It outlines the numerous failures and shows how the investigating committee ignored some of the more important ones. The diagram is useful for investigating committees, but when enlarged as a generic blueprint for an ‘organizational learning system’, as it is in the final chapter, it mimics the failure of 1960s system theory: everything is (equally) important, connected and must be taken into account.[138] (p. 607)
7.3. Turner’s Citation of Perrow
account shares with man-made disasters the view that major accidents in socio-technical systems arise from the interaction of a chain of unanticipated errors and misunderstood events in complex and ill-structured situations. However, the basic model differs from man-made disasters, being focused primarily upon the prior structural properties of complex technical systems, rather than upon the ways in which disasters develop unseen over time.[10] (p. 178)
In practice the concepts of ‘complexity’ and ‘coupling’ have turned out to be difficult to use analytically and it seems likely that they are not fully independent from each other, in that both express aspects of the fundamental complexity underlying dynamic and ill-structured systems. … Perrow’s original account appears overly deterministic, having been derived in the main from an analysis of the structural properties of technology and technological systems. … he does not clearly specify … whether similar effects are produced by both organizational and technical complexity and interdependence. However, his analysis does … [draw] attention to the safety implications of the growing complexity and interdependence of today’s most advanced industrial systems.[10] (pp. 179, 230)
8. Citation and Acknowledgment of Turner by Other Important Accident Causation and Theory Scholars
8.1. Citation of Man-Made Disasters and Normal Accidents
8.2. Andrew Hale
the fascinating thing about Barry was that he was coming at things from a very different disciplinary background, sociology, while interacting with people coming mostly from an engineering science or psychology background. So his point of view was very new, but because he wrote so eloquently and his work was so readable, he had a big influence. You could say that he was there at the right moment to give that push to include sociological factors in the causation frameworks.[223] (p. 66)
8.3. Karl Weick
continuum of loose-tight coupling reflects the way in which [Turner’s] hierarchy, power, distributed problem solving, suppressed conflict, and socialization pressures either enhance diversity through looser coupling or discourage it through tighter coupling. Likewise, the continuum of linear transformation—interactive complexity reflects the ways that Turner’s (1978) modes of operation, simultaneous consideration of problems at multiple levels of generality, conflicting actions, and discontinuities of practice make for more or less knowable chains of consequence. To worry about normal accidents is to worry about what it means to organize. As Turner put it, ‘It could be said that organizations achieve a minimal level of coordination by persuading their decision-makers to agree that they will all neglect the same kinds of consideration when they make decisions’ (p. 166; Turner and Pidgeon, 1997, p. 138). The main differences between Turner and Perrow and the rest of us lie in what each would say is the focus of that coordinated neglect.[228] (p. 29)
8.4. Jens Rasmussen
8.5. James Reason
It is, I believe, fitting to begin this survey of alternative theoretical views with Barry Turner, a sociologist at the University of Exeter, who—if he didn’t actually coin the term ‘organizational accident’—laid the groundwork for understanding organizational breakdown in his pioneering book Man-Made Disasters in 1978. Later, Turner’s work was updated in a second edition … His most important concept was ‘incubation’. In other words, organizational disasters develop over long periods of time—in short they incubate within the system. Warning signs are ignored or misunderstood or even integrated into the pattern of organizational ‘normalcy’. As a result, safeguards and defences either do not get built or are allowed to atrophy. … Disasters, as noted elsewhere, are immensely diverse in their surface details. But Turner and Pidgeon have identified a set of developmental stages that appear universal. … These notions do not necessarily conflict with the idea of latent conditions: rather, their sociological emphasis upon cultural adjustments enriches them.[234] (pp. 99–100)
A multiplicity of minor causes, misperceptions, misunderstandings and miscommunications accumulate unnoticed during this ‘incubation period’. These preconditions which one researcher has subsequently called ‘pathogens’ (Reason, 1990) stay in place in the organization or managerial practice, ready to contribute to a major failure unless something happens to neutralize them by bringing them out into the open. … They constitute an accident waiting to happen…. Brought together by some trigger event. … the underlying pattern of the incubation period is common, and recurs in many disasters and in many industries.[43] (pp. 216–218)
8.6. Diane Vaughan
Turner, investigating ‘man-made disasters’ (1976; 1978), pioneered in discovering organizational patterns that systematically contributed to the disasters he studied: norms and culturally accepted beliefs about hazards, poor communication, inadequate information handling in complex situations, and failure to comply with existing regulations instituted to assure safety (1976:391). He concluded that these factors created an absence of some kind of knowledge at some point. Crucial to understanding such accidents, then, is discovering how knowledge and information relating to events provoking a disaster were distributed in an organization before the incident (1978:3). Analysis of the Challenger accident not only confirms Turner’s findings about the relevance of knowledge and information in organizations, but also identifies structural factors that systematically affected the distribution of information and its interpretation at NASA: the competitive environment, the organization’s structure, processes, and transactions, and the regulatory environment. These factors combined to affect the decision to launch.[269] (p. 248)
Published in 1978 and accompanied by two articles in well-regarded journals in the United States, the book nonetheless was seldom cited. The book had a cult following that advertised it by word of mouth. But the failure to become integral to mainstream sociology seems odd, given the quality of his work, its grounding in general organizational principles … Moreover, his approach was unprecedented. … Turner examined … preconditions, locating them in organizational systems. He was the first to demonstrate how technical, social, institutional and administrative arrangements, in combination, can systematically produce disasters. … Looking back, we must marvel not only at Turner’s prescience, but at his accomplishment. … classic ideas … Turner’s book contains two: the title … and his core idea of ‘failures of foresight’, which directs attention to a singularly important causal element that he found. … Man-made disasters not only had preconditions, but those preconditions had characteristics in common: long incubation periods studded with early warning signs that were ignored or misinterpreted. For Barry Turner, man-made disasters were distinguished not only by the institutional, organizational, and administrative structures associated with them, but by their process. In my view, this was his true intellectual breakthrough: disasters were not sudden cataclysmic events; they had long gestation periods. We must also marvel at the methodology and analysis on which his theoretical insights were based. … Using a grounded theory approach, Turner examined these archival data, identifying similarities and differences between these cases. … His effort produced a volume with richness that goes beyond his two key concepts. For example, his understanding of the relationship between information, error, and surprise in organizations was also farsighted.[211] (pp. xii–xviii)
8.7. Nancy Leveson
8.8. Andrew Hopkins
8.9. Erik Hollnagel
The distinction between work-as-imagined and work-as-done is often used in the ergonomics literature … Work-as-imagined represents what designers, managers, regulators and authorities believe happens or should happen, whereas work-as-done represents what actually happens. Differences … [are] classified as non-compliances, violations, errors or as performance adjustments and improvisations, depending on how one looks at it. An early discussion of this in the context of safety is found in Turner, B. (1978) Man-Made Disasters.[286] (p. 38, emphasis in original)
8.10. Sidney Dekker
Defences-in-depth thinking (e.g., latent errors or resident pathogens that are already present and help incubate disaster (Reason, 1990); High reliability theory (e.g., weak signals that do not get communicated or picked up (Weick & Sutcliffe, 2001); Safety culture research (e.g., organizational cultural preconditions for disaster); Concepts such as the normalization of deviance (Vaughan, 1996), procedural drift (Snook, 2000), and drift into failure (Dekker, 2011), which all refer to disaster incubation in one way or another; Control-theoretic notions about erosion and loss of control (Leveson, 2012): the kind that Turner talked about in sociological, managerial, and administrative terms.[297] (pp. 220–221)
8.11. Acknowledgment and Citation by Seven other Accident Causality and Explanation Scholars
Before Perrow’s [1984] NA, in 1978, Turner published Man-Made Disasters, the failure of foresight, a book looking into disasters from a sociotechnical perspective (Turner, 1978). The contribution of Turner at the time was to go beyond an engineering view of disasters and to understand, study and conceptualise these events as … engineering, organisational and cultural phenomena. Accidents are the products of fallible institutionalised views created by a wide range of actors of organisations.[4] (p. 126)
9. Discussion
9.1. Turner and Perrow
9.2. Citation and Acknowledgment
9.3. Limitations
10. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
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Turner’s MMD 1978 | Perrow’s NA 1984 |
---|---|
Multiple high-risk industry qualitative case documents | Multiple high-risk industry qualitative case documents |
Patterns found in cases from inquiries | Patterns found in cases from inquiries |
Organisational Sociology and Weberian background | Organisational Sociology and Weberian background |
Technology and high-risk location important | Technology and high-risk location important |
Man-made disaster focus (13–14, 190) | Man-made catastrophe focus (3, 11, 351) |
Organisational failure (66, 75–78, 199–200) | Organisational failure (233, 330–331) |
Socio-technical (2–3, 5, 8, 47–48, 89, 170, 185, 187–188) | Socio-technical (3, 7, 9, 10–11, 352) |
Systemic (19, 135–136, 141–142, 145, 158–159, 161–162, 185, 188) | Systemic (3, 10, 62–71, 351) |
Open systems/external environment (136, 151, 170, 201) | Open systems and external environment (75) |
Emergence and propagation (89, 135, 158, 180) | Emergence and propagation (9–10) |
Failures of control (7, 70, 191) | Failures of control (81, 83) |
System forgiveness (19–20) | Cybernetic self-correcting and error-avoiding systems such as aviation (11, 79–81, 126–127, 146–147, 167–168) |
Error magnification/feedback amplification (179–181, 187, 236) | Negative synergy, error inducing systems, magnification, unfamiliar or unintended feedback loops (82, 88, 98) |
Precursor contributory factors combine in complex, unexpected and discrepant ways to defeat safety systems (86, 88, 105, 126) | Interactive complexity: small failures and other unanticipated interactions can cause system accidents (4–5, 7, 10, 101) |
Complex large-scale accidents and disasters with multiple chains of causes (14, 23–24, 75–76, 89, 105, 187) | Complex system accidents and catastrophes with multiple causes (7, 70–71, 75, 78, 85–86, 88) |
Precipitating or triggering incident or event, last event is not focus (81, 88–90, 102, 107, 122, 150, 155–156, 193, 198) | Trigger event and particular events are not the focus (6–7, 71, 342, 344) |
Surprise and unanticipated events (86, 126, 138, 145–146, 151, 159, 169, 184–186) | Unanticipated and unexpected outcomes from interactions (6, 70, 78) |
Large-scale accidents, rare catastrophes (149–151, 178) | System accidents, rare catastrophes (343–345) |
Latent structure of incubation events (86–87, 89, 94, 193) | Independent factors lying fallow for the fatal spark (111) |
Less complex accidents separate from disasters (88–89, 99) | Component failure accidents with ‘DEPOSE’ factors (8, 77, 111, 343) separate from system accidents (70) |
Bounded rationality and satisficing (133–138, 161) | Bounded rationality (315–321, 323–324) |
Inability to see or comprehend hazard (93–95, 195, 198) | Inability to see or comprehend hazard (9, 75, 351) |
Gap between perceived and actual reality (84, 94, 128–129, 138, 161, 194) | Gap between perceived and actual reality (9, 75) |
Warnings not heeded or discerned (19, 61, 194–195) | Warnings ignored or didn’t fit mental model (10, 31, 351) |
Miscommunication and misinformation (45–47, 61, 64–67, 121–124, 139) | Misinterpretation and indirect information sources (35, 73, 84) |
Variable disjunction of information (50–52, 61, 101, 217, 225) and social construction of reality (165–166, 191) | Cognitive models of ambiguous situations and the social construction of reality (9, 75, 176) |
Don’t blame individual operator error (160, 162–163, 198) | Don’t blame individual operator error (4, 9, 331, 351) |
Importance of power/elites (4, 72, 124–125, 132, 152, 191) | Importance of power/elites (12, 155, 306, 311, 339, 352) |
Growing concentration and power of large organisations and energy sources (1–2, 4–6, 160, 199, 201) | Growing concentration of energy sources and power of large organisations (102, 306, 311) |
Intentional misinformation by managers (118, 125, 147) | Deception and lying, false logs by ship captains (10, 187) |
Regulatory issues/inadequacies (70–1, 79, 87, 99, 103–4) | Regulatory issues/inadequacies (3, 176, 343) |
Gap in defences and failure of precautions (84, 87, 91) | Defence in depth limits and failures (3–4, 43, 60) |
Intuition, tacit knowledge, craft (11, 25, 51) | Intuition and use of heuristics (316–7, 319) |
Poor and unrealistic management (63, 66–67, 77, 79) | Poor management (111–112, 177, 343) |
Environmental disasters (2, 5–6, 14, 128, 131, 149, 190) | Eco-system disasters (233, 252–253, 255, 295–296) |
Societal culture and context (84, 192) | Societal values and culture (12, 315–316, 321–328) |
Importance of learning from near misses (96, 182) | Aviation occurrence reporting model important (167–169) |
Turner’s MMD 1978 | Perrow’s NA 1984 |
---|---|
Organisational and social unit focus (160, 186, 199) | Macro industry and technology focus (3, 12–14, 339) |
Multidisciplinary approach and theories are necessary to study large-scale accidents and disasters (31–32, 38, 127) | Own theory and radical critical paradigm mostly applied to high-risk accident reports and industry data |
Somewhat optimistic about learning and prevention (32, 75–80, 194–200) | Somewhat pessimistic about learning and prevention (32, 60, 257, 343, 351) |
Incubation network (86–89, 99–107, 125, 131, 193, 200) | Inevitable normal or system accidents—irretrievable for at least some time (3–5, 256, 328, 330) |
Disaster timing usually after a long incubation often of years (87, 105, 180, 193) | Disaster timing rapid: unanticipated system interaction combined with external factors (4–5, 75, 233, 253–255) |
Disasters require focused unintended organising attention on multiple fronts to occur (180) | Banality and triviality lie behind most catastrophes (9) |
Sequence model with 6 stages (84–92) | Close or tight coupling with little slack (4–6, 10–11, 89–96, 330–332) |
Failures of intention (4, 128–131, 160, 171, 181) and of foresight (50, 77, 92, 99, 107, 161, 170, 179) | Garbage can theory helps explain randomness of system accidents (324) |
Schematic accident representation diagram (97–98) | 2 × 2 matrix or grid of complexity and coupling (97, 327) |
Hierarchy of levels of information (145) | Catastrophic potential of risky technologies especially where complex and tightly coupled systems (342–346) |
Sub-cultures and shared social context determine perception (4, 58, 78, 101, 120–121, 166–171) | Capitalist production imperatives and distorted market prices are important (310–313) |
Bounded decision zones and perceptual horizons in an organisational worldview (58–9, 120–121, 165, 168–171, 200) | Common mode failures (72–73, 75, 85) |
Ill-structured problems; confusion across organisations and divisions (19–22, 50, 52–53, 60, 72, 75, 77, 96, 107) | Unnecessary proximity and tight spacing can lead to unexpected interactions (82, 85, 88) |
Well-structured problem post-disaster (52, 74–76, 103, 106, 179–188) | Centralisation and decentralisation (10, 331–335) |
Intended actor rationality (129, 160, 171–178, 200) | Social rationality by non-experts in society (315–6, 321–324) |
Negentropy, anti-tasks and non-random structured nature of unintended consequences (127, 179, 181, 187, 190) | Understanding of transformational designs and processes is limited (11, 84–86, 330) |
Discrepant information and events (86–90, 122, 146) | Externalities imposed on society (339–341) |
Importance of organisational culture (77, 103) | Incomprehensibility of system accidents (23, 277) |
Catastrophe and chaos theory (153–156, 185–187, 194) | Complex systems seek productive efficiency (88) |
Misdirected energy and misinformation (4, 182–184, 187, 189–191, 193) | Risk assessment has a narrow focus; typically assumes over-regulation (306–314) |
Decoy problem takes the focus off more serious threats (59–61, 64, 78, 80, 86–87, 100, 102–104, 196) | Risk assessor ‘shamans’ support elites’ use of ‘evil’ technologies (12, 14, 307); some scientists, engineers and cognitive psychologists complicit (14, 307, 316–320) |
Complaints from outsiders discounted; reluctance to fear the worst (73–74, 76, 102–104) | Social class distribution of risk, inequality linked to disproportionate risk (310) |
Social and differentiated distribution of knowledge (3, 85, 106, 152) | Error-inducing systems such as marine shipping (11, 173–176, 181–190, 230) |
Channels of observation not just communication (141, 159); what organisations pay attention to (58, 163–171) | Nuclear accidents like TMI, unreliability and inevitability (15–61, 344, 348) |
Nuclear industry’s enormous hazards—but risk analysis, information and response (1–2, 18, 29–30, 35, 183) | Normative advocacy; technologies like nuclear power and weapons should not be used (x, 14, 347–52) |
Knowledge of Turner (MMD 1978 or after 1997 2nd edn) | Acknowledgment of Turner’s Ideas | Knowledge of Perrow’s NA (1984 or 1999) | Acknowledgment of Perrow’s Ideas | |
---|---|---|---|---|
Hale | MMD 1978 | mixed | NA | good |
Weick | 2nd edn 1997 | good | NA | good |
Rasmussen | Unclear | poor | unclear | poor |
Reason | MMD 1978 | poor/mixed | NA | good |
Vaughan | MMD 1978 | good/mixed | NA | good |
Leveson | MMD 1978 | mixed/poor | NA | good |
Hopkins | 2nd edn 1997 | good | NA | good |
Hollnagel | 2nd edn 1997 | mixed | NA | good |
Dekker | 2nd edn 1997 | mixed/good | NA | good |
Shrivastava | MMD 1978 | mixed | NA | poor |
Sagan | Unclear | poor | NA | good |
Snook | pre MMD 1978 | poor | NA | good |
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Bills, K.; Costello, L.; Cattani, M. Barry Turner: The Under-Acknowledged Safety Pioneer. Safety 2023, 9, 68. https://doi.org/10.3390/safety9040068
Bills K, Costello L, Cattani M. Barry Turner: The Under-Acknowledged Safety Pioneer. Safety. 2023; 9(4):68. https://doi.org/10.3390/safety9040068
Chicago/Turabian StyleBills, Kym, Leesa Costello, and Marcus Cattani. 2023. "Barry Turner: The Under-Acknowledged Safety Pioneer" Safety 9, no. 4: 68. https://doi.org/10.3390/safety9040068