A systems thinking approach to safety in Norwegian avalanche rescue operations

Abstract

Snow avalanches crossing roads constitute a major safety challenge to both road users and avalanche rescuers in Norway. In this paper, we reassess the current emergency response situation by using systems safety theory. The rescue system is regulated and operated through instructions and guidelines that are based on critical assumptions. We designed the study to challenge critical assumptions in the organized complex rescue system using experiences from operational experts. In two seminars the experts conducted a systemic safety analysis based on the “Systems-Theoretic Accident Model and Processes” (STAMP) approach and the “Systems-Theoretic Process Analysis” (STPA) technique, deriving goals, hazards, requirements, constraints, a safety control structure and unsafe control actions. The gap analysis revealed that both dispatchers and emergency services are commonly not provided with the recommended training and basic avalanche safety equipment. The causal analysis provided common explanations of recurrent unsafe control actions, allowing plausible accident scenarios to be identified. This study supports a recommendation that the safety control structure of the Norwegian avalanche rescue service should be operationalized in accordance with assumptions and requirements. Contrary to critics, the STAMP/STPA systemic safety analysis proved manageable and productive, as it unceasingly directed the analyst’s attention towards organizational challenges at the blunt end.