The Fundão Tailings Dam Catastrophe …
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4 Managing the Unexpected
Unexpected events can get you into trouble unless you create a mindful infrastructure that continually tracks small failures, resists oversimplification, is sensitive to
operations, maintains capabilities for resilience, and monitors shifting locations of
expertise (Weick and Sutcliffe 2007, p. 21). In this context, the authors claim that the
nature of unexpected events occurs in three ways: (i) when an event that was expected
to happen fails to occurs; (ii) when an event that was not expected to happen does
happen; and (iii) when an event that was simply unthought of happens. A significant
action for managing the HROs is to improve understanding of the third form of the
unexpected and to expand knowledge toward mindful practices (Weick and Sutcliffe
2007, p. 29).
In HROs, reifications may lead to established paradigms within safety and emergency management. Emergency is commonly defined as “the totality of technical,
operational, and organizational efforts preventing a hazard from developing into an
accident, or reducing the damage from the accident” (Aase and Tjensvoll 2014). In
HRO literature, emergency can be defined as training, preparation, and management
of something unexpected, surprising, and complex (Weick and Sutcliffe 2001).
Learning in high-reliability organizations and emergency management that strive
for high performance in things they can plan for, can result in highly reliable organizations that are better able to manage unexpected events for which plans cannot
be made by definition (Aase and Tjensvoll 2014; Caro 2016). The scale of possible
consequences from errors or mistakes precludes learning through experimentation.
5 Method
The present study is a qualitative in-depth case study (Stake 2001). The purpose
of the study was to analyze the catastrophe of the Fundão tailing dam under the
lens of complexity and emergency theories, sustainable sciences and management
of complex systems, seeking explanations and learning lessons of the disaster.
The rigor of qualitative research can be seen in efforts to verify and validate the
meaning of documents, official reports and articles published in the media about the
event. The data collection required ability to deal with a wide variety of evidence.
The diverse data were compared and, from these comparisons, the research resulted
in relevant findings. The data were processed using a three-step content analysis
technique: (a) pre-analysis; (b) material exploration; and (c) processing of the results
and interpretation (Bardin 2010).
389
4 Managing the Unexpected
Unexpected events can get you into trouble unless you create a mindful infrastructure that continually tracks small failures, resists oversimplification, is sensitive to
operations, maintains capabilities for resilience, and monitors shifting locations of
expertise (Weick and Sutcliffe 2007, p. 21). In this context, the authors claim that the
nature of unexpected events occurs in three ways: (i) when an event that was expected
to happen fails to occurs; (ii) when an event that was not expected to happen does
happen; and (iii) when an event that was simply unthought of happens. A significant
action for managing the HROs is to improve understanding of the third form of the
unexpected and to expand knowledge toward mindful practices (Weick and Sutcliffe
2007, p. 29).
In HROs, reifications may lead to established paradigms within safety and emergency management. Emergency is commonly defined as “the totality of technical,
operational, and organizational efforts preventing a hazard from developing into an
accident, or reducing the damage from the accident” (Aase and Tjensvoll 2014). In
HRO literature, emergency can be defined as training, preparation, and management
of something unexpected, surprising, and complex (Weick and Sutcliffe 2001).
Learning in high-reliability organizations and emergency management that strive
for high performance in things they can plan for, can result in highly reliable organizations that are better able to manage unexpected events for which plans cannot
be made by definition (Aase and Tjensvoll 2014; Caro 2016). The scale of possible
consequences from errors or mistakes precludes learning through experimentation.
5 Method
The present study is a qualitative in-depth case study (Stake 2001). The purpose
of the study was to analyze the catastrophe of the Fundão tailing dam under the
lens of complexity and emergency theories, sustainable sciences and management
of complex systems, seeking explanations and learning lessons of the disaster.
The rigor of qualitative research can be seen in efforts to verify and validate the
meaning of documents, official reports and articles published in the media about the
event. The data collection required ability to deal with a wide variety of evidence.
The diverse data were compared and, from these comparisons, the research resulted
in relevant findings. The data were processed using a three-step content analysis
technique: (a) pre-analysis; (b) material exploration; and (c) processing of the results
and interpretation (Bardin 2010).