A systemic analysis of patterns of organizational breakdowns in accidents: A case from Helicopter Emergency Medical Service (HEMS) operations

In recent years, many accident models and techniques have shifted their focus from shortfalls in the actions of practitioners to systemic causes in the organization. Accident investigation techniques (e.g., STAMP) have been developed that looked into the flaws of control processes in the organization. Organizational models have looked into general patterns of breakdown related to structural vulnerabilities and gradual degradation of performance. Although some degree of cross-fertilization has been developed between these two trends, safety analysts are left on their own to integrate this gap between control flaws and patterns of organizational breakdown in accident investigation. This article attempts to elaborate the control dynamics of the Systems Theoretic Accident Model and Process (STAMP) technique on the basis of a theoretical model of organizational viability (i.e., the Viable Systems Model). The joint STAMP–VSM framework is applied to an accident from a Helicopter Emergency Medical Service (HEMS) organization to help analysts progress from the analysis of control flaws to the underlying patterns of breakdown. The joint framework may help analysts to rethink the safety organization, model new information loops and constraints, look at the adaptation and steering functions of the organization and finally, develop high leverage interventions.

► This article bridges the gap between two parallel trends in systemic accident models.
► Investigation techniques (i.e., STAMP) have looked into the flaws of safety management processes.
► The literature has highlighted many patterns (or archetypes) of organizational breakdowns.
► The Viable System Model is used with STAMP to link control flaws and organizational breakdowns.