Systemic Approach to Failure Analysis: A Study of Sociotechnical Organization


  • Nasir Afghan



Crisis management, Leadership, Systemic failure analysis


The paper is an attempt to explore systemic approach to accidents analysis within sociotechnical organization. Unsafe behaviors can result in systemic failures and accidents. The research data came from within an industrial radiography organization where radiation source is used to detect cracks or hidden flaws within machinery and welding joints. The radioactive source can cause severe detrimental effects, even death, if not used safely. This paper is on two isolated events happen in the same company, Industrial Services Private Limited (not real name). The company top management was dealing with the financial crisis and to maintain quality of its services and the safety of staff. The leadership of the company made several business and operational decisions to manage the financial crisis. During that time, several near miss incidents took place, but the first major incident took place when the radiography gamma projector, along with the radioactive source, fallen out of the vehicle because of improper back door closure of the vehicle. In the second incident, the radioactive source remained unshielded after a radiography job, this caused overexposure to radiography workers. The paper provides an opportunity to understand how an organization’s leadership can create conditions for errors and mistakes that result in poor safety culture and ultimately the accident which resulted the system failure and operation shutdown. The paper also tries to propose a conceptual framework to improve safety culture within the sociotechnical systems for the future research in this area.


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