Due to the complexity of the environment, organizational processes, and technical and professional skills required, there are numerous risk factors that expose the possibility of errors, and most importantly, the consequences of errors can be serious or catastrophic. Different approaches have been used for the study of errors in organizations. In particular, the safety and security literature recognized the importance of the error learning approach. In this perspective, Reason's Swisse Cheese Model represented a revolution in reading errors from a psychosocial and organizational approach. Past research has considered this model as a tool for reading and analyzing errors and preventing incidents. The present paper, on the other hand, aims to use the model not only before but also after an incident occurs, taking a dual perspective on error, prevention and management and highlighting the relevance of mitigation. To do it, the Costa Concordia incident is examined using the Swisse Cheese Model. The study attempts to consider the two temporal phases, before and after the incident, in the analysis of psychosocial, cultural-organizational, and technical factors. In doing so, the importance of the intermediate phase between the occurrence of the incident and its management emerges, in the aggravation of the consequences of errors. Overall, this research contributes to a more granular understanding of errors and incidents and to increasing the adoption of the Swisse Cheese Model, not only in the error prevention phase but also in the management one. Findings offer implications for both theory and practice.
Error Prevention and Error Management are two sides of the same coin: the application of Reason's Swisse Cheese Model before and after the incident in the case of Costa Concordia / Cova, Eleonora; Farnese, Maria Luisa. - (2024). (Intervento presentato al convegno 1st IAQUIS International Conference tenutosi a Viterbo).
Error Prevention and Error Management are two sides of the same coin: the application of Reason's Swisse Cheese Model before and after the incident in the case of Costa Concordia.
Eleonora Cova
;Maria Luisa Farnese
2024
Abstract
Due to the complexity of the environment, organizational processes, and technical and professional skills required, there are numerous risk factors that expose the possibility of errors, and most importantly, the consequences of errors can be serious or catastrophic. Different approaches have been used for the study of errors in organizations. In particular, the safety and security literature recognized the importance of the error learning approach. In this perspective, Reason's Swisse Cheese Model represented a revolution in reading errors from a psychosocial and organizational approach. Past research has considered this model as a tool for reading and analyzing errors and preventing incidents. The present paper, on the other hand, aims to use the model not only before but also after an incident occurs, taking a dual perspective on error, prevention and management and highlighting the relevance of mitigation. To do it, the Costa Concordia incident is examined using the Swisse Cheese Model. The study attempts to consider the two temporal phases, before and after the incident, in the analysis of psychosocial, cultural-organizational, and technical factors. In doing so, the importance of the intermediate phase between the occurrence of the incident and its management emerges, in the aggravation of the consequences of errors. Overall, this research contributes to a more granular understanding of errors and incidents and to increasing the adoption of the Swisse Cheese Model, not only in the error prevention phase but also in the management one. Findings offer implications for both theory and practice.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.


