The Fundão Tailings Dam Catastrophe …
395
7 Discussion
Disasters send signals, which most of the time are either not perceived, misinterpreted
or even neglected by managers and operators. When the context is a complex system,
the consequences of such behavior escalate, causing disasters with unexpected and
catastrophic consequences (Turner 1994; Perrow 1999). Typical examples of this
kind are accidents involving airlines, nuclear plants, weapons systems, chemical
plants, mining, air control and commercial aviation, and are well known. Cases like
Union Carbide (Bhopal), Three Mile Island, the Tenerife Islands KLM/PANAM
Crash, Chernobyl, British Petroleum (Gulf of Mexico) and the Air France Flight 447
disaster are representative of the collapse of complex systems.
More recently, the Fundão Dam revealed a complex system sensitive to environmental forces, and therefore, subject to errors, failures, accidents and disasters. Most
of these cases indicated human-made catastrophes. Formal investigations and reports
of disasters tend to search for particular faults or failures that lead to blame being
placed on the operators and/or managers.
The examination of the Fundão Case revealed that even though dams are not a typical example of complex tightly coupled systems, they are complex systems that are
extremely vulnerable to socio-technical failures and highly sensitive to environmental forces. Therefore, their operations were hurt by both unexpected events stemming
from topological nature (seismic shocks) plus human errors by operational people
and mismanagement and technical negligence.
The lessons learned from the case can be classified into two kinds, each of them
requiring distinct stances and clear responses to two crucial problems: lack of supervision and unsustainable managerial malpractices, both of them linking mistakes,
misconduct and disaster (Vaughan 1999). As the first problem indicated, there is a
need to inculcate a mindfulness principle or mentality (Weick and Sutcliffe 2006)
within the company, particularly among the technicians in charge of inspecting the
dam, contributing to building a more reliable and safer system. The mindfulness
approach leads to the examination of contingencies as a way to cope with failures
and manage unexpected events (Weick and Sutcliffe 2006; Sutcliffe 2011).
The second problem dealt with the signals sent by the imminent disaster, which
were initially incubated (Turner 1994) and later unnoticed, misinterpreted and even
neglected by operators and managers. When the context is a complex system like
the Fundão dam, the consequences escalated, with unexpected and catastrophic outcomes (Turner 1994; Perrow 1999). To what extent could the Fundão Dam catastrophe have been avoided? This is quite a difficult question to answer, but the fact is that
the nature of the catastrophe that caused the destruction of a small town, deaths and
serious social, economic and environmental damages in a large region require strong
responses. In this respect, the building of a more reliable (Weick 1987; Roberts 1990,
2011), safer (Levenson et al. 2009; Catrino and Patriotta 2013) and complex responsive system (Stacey 2010) will be required to enhance the performance of complex
systems and achieve sustainable development (Sachs 2015).
395
7 Discussion
Disasters send signals, which most of the time are either not perceived, misinterpreted
or even neglected by managers and operators. When the context is a complex system,
the consequences of such behavior escalate, causing disasters with unexpected and
catastrophic consequences (Turner 1994; Perrow 1999). Typical examples of this
kind are accidents involving airlines, nuclear plants, weapons systems, chemical
plants, mining, air control and commercial aviation, and are well known. Cases like
Union Carbide (Bhopal), Three Mile Island, the Tenerife Islands KLM/PANAM
Crash, Chernobyl, British Petroleum (Gulf of Mexico) and the Air France Flight 447
disaster are representative of the collapse of complex systems.
More recently, the Fundão Dam revealed a complex system sensitive to environmental forces, and therefore, subject to errors, failures, accidents and disasters. Most
of these cases indicated human-made catastrophes. Formal investigations and reports
of disasters tend to search for particular faults or failures that lead to blame being
placed on the operators and/or managers.
The examination of the Fundão Case revealed that even though dams are not a typical example of complex tightly coupled systems, they are complex systems that are
extremely vulnerable to socio-technical failures and highly sensitive to environmental forces. Therefore, their operations were hurt by both unexpected events stemming
from topological nature (seismic shocks) plus human errors by operational people
and mismanagement and technical negligence.
The lessons learned from the case can be classified into two kinds, each of them
requiring distinct stances and clear responses to two crucial problems: lack of supervision and unsustainable managerial malpractices, both of them linking mistakes,
misconduct and disaster (Vaughan 1999). As the first problem indicated, there is a
need to inculcate a mindfulness principle or mentality (Weick and Sutcliffe 2006)
within the company, particularly among the technicians in charge of inspecting the
dam, contributing to building a more reliable and safer system. The mindfulness
approach leads to the examination of contingencies as a way to cope with failures
and manage unexpected events (Weick and Sutcliffe 2006; Sutcliffe 2011).
The second problem dealt with the signals sent by the imminent disaster, which
were initially incubated (Turner 1994) and later unnoticed, misinterpreted and even
neglected by operators and managers. When the context is a complex system like
the Fundão dam, the consequences escalated, with unexpected and catastrophic outcomes (Turner 1994; Perrow 1999). To what extent could the Fundão Dam catastrophe have been avoided? This is quite a difficult question to answer, but the fact is that
the nature of the catastrophe that caused the destruction of a small town, deaths and
serious social, economic and environmental damages in a large region require strong
responses. In this respect, the building of a more reliable (Weick 1987; Roberts 1990,
2011), safer (Levenson et al. 2009; Catrino and Patriotta 2013) and complex responsive system (Stacey 2010) will be required to enhance the performance of complex
systems and achieve sustainable development (Sachs 2015).