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6 Justifying the Need for New Approaches
1. Failures—in the sense of human intentions not being fulfilled—are fundamentally due to human factors;
2. Failures are caused by a complex interaction of relatively common physical,
human, organizational, and industry factors;
3. Numerous human, organizational, and industry factors lead to the physical factors
not being adequately recognized and properly addressed;
4. “The dominant risks to be managed in dam safety derive not from unique events
but from adverse combination of more usual events. One might think of these as
unusual combinations of usual conditions … These include the systems interactions among management policy, procedural factors, instrumentation …, operational and maintenance practices, design flaws, construction compromises, deterioration, outside disturbances, and many other things that are often overlooked
at the time of design. The result is that many system failures do not fit within
a traditional engineering-analytic framework and a new systems framework is
needed.”
5. The new framework should:
• Provide a thorough understanding of the wide scope of human factors that
may detract from the degree of risk protection with particular attention to
their impact on activities such as judgments, decisions, actions, inactions,
influencing situational factors, and interactions;
• Require a detailed understanding of the systems to be managed based periodic
comprehensive reviews as the basis for reliable and quantified input to a risk
assessment process. This would require more in-depth reviews than usually
mandated and would include:
– Current standards and states of practice;
– A review of all available data;
– Critical and independent thinking;
– Completed by people with appropriate technical expertise, experience, and
qualifications to cover all aspects of design, construction, maintenance,
repair, and failure modes of the assets under consideration.
• Utilize expanded risk assessment approaches that would address:
– Difficulties in properly characterizing risks for large or complex systems,
including accounting for human and operational aspects in failures;
– The tendency to oversimplify complex failure modes involving multiple
interactions of system components by defining failure modes as a linear
chain of events;
– The need to consider how broader organizational factors, such as culture
and decision-making authority and practices, can contribute to failure.
6 Justifying the Need for New Approaches
1. Failures—in the sense of human intentions not being fulfilled—are fundamentally due to human factors;
2. Failures are caused by a complex interaction of relatively common physical,
human, organizational, and industry factors;
3. Numerous human, organizational, and industry factors lead to the physical factors
not being adequately recognized and properly addressed;
4. “The dominant risks to be managed in dam safety derive not from unique events
but from adverse combination of more usual events. One might think of these as
unusual combinations of usual conditions … These include the systems interactions among management policy, procedural factors, instrumentation …, operational and maintenance practices, design flaws, construction compromises, deterioration, outside disturbances, and many other things that are often overlooked
at the time of design. The result is that many system failures do not fit within
a traditional engineering-analytic framework and a new systems framework is
needed.”
5. The new framework should:
• Provide a thorough understanding of the wide scope of human factors that
may detract from the degree of risk protection with particular attention to
their impact on activities such as judgments, decisions, actions, inactions,
influencing situational factors, and interactions;
• Require a detailed understanding of the systems to be managed based periodic
comprehensive reviews as the basis for reliable and quantified input to a risk
assessment process. This would require more in-depth reviews than usually
mandated and would include:
– Current standards and states of practice;
– A review of all available data;
– Critical and independent thinking;
– Completed by people with appropriate technical expertise, experience, and
qualifications to cover all aspects of design, construction, maintenance,
repair, and failure modes of the assets under consideration.
• Utilize expanded risk assessment approaches that would address:
– Difficulties in properly characterizing risks for large or complex systems,
including accounting for human and operational aspects in failures;
– The tendency to oversimplify complex failure modes involving multiple
interactions of system components by defining failure modes as a linear
chain of events;
– The need to consider how broader organizational factors, such as culture
and decision-making authority and practices, can contribute to failure.