394
V. Meyer Jr. et al.
second major fault. These studies were not presented when the second license for the
construction was issued. A report by the engineering consultancy firm contracted by
Samarco warning about the danger of water compromising the safety of the Fundão
was found by public representatives during investigation (Serra 2018).
Looking back, it is crystal clear that unsustainable malpractices represented by
multiple neglected aspects in the technical and managerial areas, weakening layers of
control, during a long period of time, also created the conditions for the catastrophe.
In fact, both the technical and managerial failures produced each other recursively,
as can be seen regarding the issue of controls (Turner 1994).
Even though the use of supervision and control in complex systems is a form of
promoting reliability in the system, avoiding mistakes and errors, the same system
paradoxically tends to lead to complaisance and paves the way for accidents and
disasters (Smith and Lewis 2011). Although it seems obvious that controls should
be deployed, reinforced and evaluated as a way to avoid such events, this is only
partially appropriate because there are important limitations.
Disasters are socio-technical events. Some are caused by management inadequacies or unprofessional behavior, while others occur when disaster conditions are
generated as a result of the normal operation of larger administrative and technical
systems. Only a small number of significant accidents have technical causes. Most
have social, administrative or managerial causes. The same rates apply to corrective measures and recommendations. Thus, it is necessary to consider not only the
technical controls, but also the managerial ones, with emphasis on these.
Significant accidents have preconditions that are emerge over time. Minor
causes, misperceptions, misunderstandings and communication failures accumulate
unnoticed, with accidents waiting to happen. These variables exist in management
organization or practices, ready to contribute to a major accident, unless something
neutralizes them. Moreover, there are trade-offs, ambiguities, and paradoxes that set
limits on management practices.
Although Turner (1994) considered as trade-offs the mutually incompatible
demands of the technical systems, with respect to technical and managerial controls
(e.g., fast decisions versus accurate, strong and well-defined hierarchical structures
versus involvement of the lower levels of the organization; quality decision processes
that use masses of data), non-technical elements also impose trade-offs. For example, high indebtedness and falling iron ore prices led Samarco managers to focus
on financial management and the recovery of the profit margin to the detriment of
investments in risk prevention.
The disaster caused by the collapse of the Fundão Dam revealed much irreparable
damage (Serra 2018). Not only the known consequences, but new situations were
identified after the catastrophe. One of these was the case of shrimp fishermen from
Vitória, the capital of Espírito Santo State. In April 2018, t was recognized that they
were also affected by the disaster, even though the region is apparently far from the
Fundão Dam. If, according to Richardson (2008), the central element of a complex
system is nonlinear feedback, which allows for emergence, self-organization, adaptation, learning, and others terms used as synonyms for complex thinking, it is time
to revise technical, managerial and sociotechnical practices.
V. Meyer Jr. et al.
second major fault. These studies were not presented when the second license for the
construction was issued. A report by the engineering consultancy firm contracted by
Samarco warning about the danger of water compromising the safety of the Fundão
was found by public representatives during investigation (Serra 2018).
Looking back, it is crystal clear that unsustainable malpractices represented by
multiple neglected aspects in the technical and managerial areas, weakening layers of
control, during a long period of time, also created the conditions for the catastrophe.
In fact, both the technical and managerial failures produced each other recursively,
as can be seen regarding the issue of controls (Turner 1994).
Even though the use of supervision and control in complex systems is a form of
promoting reliability in the system, avoiding mistakes and errors, the same system
paradoxically tends to lead to complaisance and paves the way for accidents and
disasters (Smith and Lewis 2011). Although it seems obvious that controls should
be deployed, reinforced and evaluated as a way to avoid such events, this is only
partially appropriate because there are important limitations.
Disasters are socio-technical events. Some are caused by management inadequacies or unprofessional behavior, while others occur when disaster conditions are
generated as a result of the normal operation of larger administrative and technical
systems. Only a small number of significant accidents have technical causes. Most
have social, administrative or managerial causes. The same rates apply to corrective measures and recommendations. Thus, it is necessary to consider not only the
technical controls, but also the managerial ones, with emphasis on these.
Significant accidents have preconditions that are emerge over time. Minor
causes, misperceptions, misunderstandings and communication failures accumulate
unnoticed, with accidents waiting to happen. These variables exist in management
organization or practices, ready to contribute to a major accident, unless something
neutralizes them. Moreover, there are trade-offs, ambiguities, and paradoxes that set
limits on management practices.
Although Turner (1994) considered as trade-offs the mutually incompatible
demands of the technical systems, with respect to technical and managerial controls
(e.g., fast decisions versus accurate, strong and well-defined hierarchical structures
versus involvement of the lower levels of the organization; quality decision processes
that use masses of data), non-technical elements also impose trade-offs. For example, high indebtedness and falling iron ore prices led Samarco managers to focus
on financial management and the recovery of the profit margin to the detriment of
investments in risk prevention.
The disaster caused by the collapse of the Fundão Dam revealed much irreparable
damage (Serra 2018). Not only the known consequences, but new situations were
identified after the catastrophe. One of these was the case of shrimp fishermen from
Vitória, the capital of Espírito Santo State. In April 2018, t was recognized that they
were also affected by the disaster, even though the region is apparently far from the
Fundão Dam. If, according to Richardson (2008), the central element of a complex
system is nonlinear feedback, which allows for emergence, self-organization, adaptation, learning, and others terms used as synonyms for complex thinking, it is time
to revise technical, managerial and sociotechnical practices.