Disasters are often tragic outcomes of high-risk technologies such as mines. No matter how effective our conventional safety devices are, there is a form of accident that appears to be ‘inevitable’, yet preventable. These relate to accidents that result from "interacting failures" in a way that could not be foreseen by the designers. In so-called "tightly coupled production systems" (processes that happen very fast, such as on a high producing mine) the risk is even higher and our risk controls mostly introduce some sort of a technological fix. While we are with the one hand attempting to control the risk, we are also with the other hand, introducing more levels of complexity, through the acts of risk controlling. Are we really controlling the risk?
This is one of the fundamental questions that will be addressed in this paper: Do we have the ability as an industry to effectively prevent these catastrophes, or are we, on the contrary, faced with an increasing risk as a result of increasing complexities of our technology and management systems and practices. This paper will contend that a perceived improvement in risk control is an illusion of activity, and that the likelihood of catastrophes may be increasing.
This paper will further contend that we are applying the right solutions to the wrong problems. Our focus is technological and procedural, while our problem is one of production cultures ‘ripe for error’ and for ‘incremental collapse’ - a slow process of degradation of safety defenses, as a result of expanding confidence in the same defenses.
Risk is like beauty - it exists in the eye of the beholder. We make a fundamental mistake when we, as safety managers, deal with risk as a "fixed attribute", something physical that can be precisely measured and managed.
The misconception of risk as a fixed attribute is ingrained into our industry and is a product of the so-called science of risk management. Risk management has created the illusion that risk can be quantified on the basis of probability, exposure to risk, and from the likely consequences of accidents occurring. Risk management science can even produce highly technical and mathematically advanced models of the probabilistic nature of a risk.