Limitations of Event Chain Models(2) Human error Deviation from normative procedure Vs established practice Cannot effectively model human behavior by decomposing it into individual decisions and actions and studying it in isolation from the physical and social context value system in which it takes place dynamic work process Adaptation Major accidents involve systematic migration of organizational behavior under pressure toward cost effectiveness in an aggressive, competitive environment Vessel Passenger management ardo Excess numbers Berth design Berth design Zeebrugge Traffic Scheduling Unsafe Transfer of Heral 冖 Captains planning Crew Operation partments in operational context ble accidents ery likely will not see the forest can easily be identifiedc ✎✞✝✞✏✄✝✞✍✄☛✞✟☞✑③❏❑▲✞❾ ￾✂✁✄✁✄☎✆✞✝✞✟✞✠✞✡☞☛✞✆✞✝✞✌✍ Limitations of Event Chain Models (2) Human error Deviation from normative procedure vs. established practice Cannot effectively model human behavior by decomposing it into individual decisions and actions and studying it in isolation from the physical and social context value system in which it takes place dynamic work process Adaptation Major accidents involve systematic migration of organizational behavior under pressure toward cost effectiveness in an aggressive, competitive environment. ✎✞✝✞✏✄✝✞✍✄☛✞✟☞✑③❏❑▲✞❿ ￾✂✁✄✁✄☎✆✞✝✞✟✞✠✞✡☞☛✞✆✞✝✞✌✍ Design Vessel Design Shipyard Equipment load added Harbor Design Cargo Calais Zeebrugge Traffic Vessel Management Passenger Management Scheduling Operation Berth design Berth design Operations management Captain’s planning procedure to Zeebrugge Transfer of Herald heuristics Operations management procedure Unsafe patterns docking Standing orders Operations management Excess numbers Passenger management Capsizing Change of Crew working Stability Analysis Truck companies Impaired stability Excess load routines Docking c Time pressure Operational Decision Making: Accident Analysis: Combinatorial structure Decision makers from separate of possible accidents departments in operational context can easily be identified. very likely will not see the forest for the trees