Abstract

There is a major dilemma that must be addressed regarding the processes we use to manage the risks of complex technologies. Why is it, with all the attention to scenario identification and risk analysis, that major industries continue to be surprised by major accidents that weren’t identified in advance and prevented from occurring? As a case in point, with all the emphasis on risk assessment following the space shuttle Challenger disaster, how could the Columbia accident occur? Are such events just the inevitable remnants of a process that can’t possibly identify all possible scenarios, or is there something wrong with the fundamental thought processes of risk management? Using experience from the nuclear, aviation, space, and oil and gas industries, this paper will explore these questions. We will compare the post-accident responses of the subject industries to these “defining events,” to see if there are discernible differences in the ability to prevent “the next accident.” Finally, we will propose steps that we believe could be effective in closing this gap between the results of our risk analysis process and the catastrophic failures we continue to see in the real world.

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