396
V. Meyer Jr. et al.
Because of its consequences locally and regionally, the Fundão Case is considered
both an emergency event and a catastrophe (Thomas et al. 2015). Therefore, due to
the nature and characteristics of the dam as a complex system, the organizational
responses required the collaborative effort of a multi interdisciplinary group of professionals and public officials and experts in the field. There is a belief that managers
of complex systems have a clear understanding of the organization beyond control
of operations and awareness of possible risks facing the system. However, as the
analysis of the case indicated, the situation of the management of the Fundão Dam
was quite different, revealing just the opposite.
After the disaster, managers underestimated its impact, and, in some cases, initial
information was distorted, helping to heighten the consequences of the catastrophe
in the eyes of the company in charge of the dam’s operations, public officials, the
community and society at large. This can be explained by the paradoxical approach
(Smith and Lewis 2011) that is typical in complex and high reliability organizations.
In this context, when opposite forces like robust systems to prevent accidents represented by the adoption of compliance systems are set, they can at the same time bring
about mindlessness behavior, which compromises both the reliability and safety of
the system.
In this case, robustness and vulnerability tend to void each other (Smith and
Lewis 2011), and therefore, impact the defense of a complex system. The Fundão
Dam catastrophe, at least partially, could be seen as an outcome of such a paradox,
representing a contribution to the reliability and safety theory, pointing out to managers of complex systems the need to find ways to integrate the two poles (Smith
et al. 2016) in order to succeed.
8 Concluding Remarks
The challenge for managing complex systems like the Fundão Tailings Dam is
twofold: the first is to build safety devices into high complex systems, whose functioning is based on the tightly coupled interaction of multiple elements of a technical,
human, environmental and political nature. These factors are somehow intertwined,
generating unpredictable or unforeseen outcomes and consequences regardless of
managerial efforts.
The second is to disseminate a culture of mindfulness (Weick and Sutcliffe 2007)
and safety (Levenson et al. 2009), spreading a continuous alert to signs of problems
that indicate mal functioning within a system. Unsafe systems do not detect the first
signs of disaster during the incubation period (Turner 1994). These are usually key
elements of an accident waiting to happen (Roberts 1990).
However, in spite of an effort to build a reliable and safe system apparatus, there is
always room for socio-technical failures such as negligence, mistakes, misconduct,
misinterpretation, neglect and sloppy management, in addition to unpredictable environmental and topological forces like seismic shocks, hurricanes and earthquakes,
which could all lead to disasters.
V. Meyer Jr. et al.
Because of its consequences locally and regionally, the Fundão Case is considered
both an emergency event and a catastrophe (Thomas et al. 2015). Therefore, due to
the nature and characteristics of the dam as a complex system, the organizational
responses required the collaborative effort of a multi interdisciplinary group of professionals and public officials and experts in the field. There is a belief that managers
of complex systems have a clear understanding of the organization beyond control
of operations and awareness of possible risks facing the system. However, as the
analysis of the case indicated, the situation of the management of the Fundão Dam
was quite different, revealing just the opposite.
After the disaster, managers underestimated its impact, and, in some cases, initial
information was distorted, helping to heighten the consequences of the catastrophe
in the eyes of the company in charge of the dam’s operations, public officials, the
community and society at large. This can be explained by the paradoxical approach
(Smith and Lewis 2011) that is typical in complex and high reliability organizations.
In this context, when opposite forces like robust systems to prevent accidents represented by the adoption of compliance systems are set, they can at the same time bring
about mindlessness behavior, which compromises both the reliability and safety of
the system.
In this case, robustness and vulnerability tend to void each other (Smith and
Lewis 2011), and therefore, impact the defense of a complex system. The Fundão
Dam catastrophe, at least partially, could be seen as an outcome of such a paradox,
representing a contribution to the reliability and safety theory, pointing out to managers of complex systems the need to find ways to integrate the two poles (Smith
et al. 2016) in order to succeed.
8 Concluding Remarks
The challenge for managing complex systems like the Fundão Tailings Dam is
twofold: the first is to build safety devices into high complex systems, whose functioning is based on the tightly coupled interaction of multiple elements of a technical,
human, environmental and political nature. These factors are somehow intertwined,
generating unpredictable or unforeseen outcomes and consequences regardless of
managerial efforts.
The second is to disseminate a culture of mindfulness (Weick and Sutcliffe 2007)
and safety (Levenson et al. 2009), spreading a continuous alert to signs of problems
that indicate mal functioning within a system. Unsafe systems do not detect the first
signs of disaster during the incubation period (Turner 1994). These are usually key
elements of an accident waiting to happen (Roberts 1990).
However, in spite of an effort to build a reliable and safe system apparatus, there is
always room for socio-technical failures such as negligence, mistakes, misconduct,
misinterpretation, neglect and sloppy management, in addition to unpredictable environmental and topological forces like seismic shocks, hurricanes and earthquakes,
which could all lead to disasters.