Recursive modeling of loss of control in human and organizational processes: a systemic model for accident analysis.

A recursive model of accident investigation is proposed by exploiting earlier work in systems thinking. Safety analysts can understand better the underlying causes of decision or action flaws by probing into the patterns of breakdown in the organization of safety. For this deeper analysis, a cybernetic model of organizational factors and a control model of human processes have been integrated in this article (i.e., the viable system model and the extended control model). The joint VSM-ECOM framework has been applied to a case study to help safety practitioners with the analysis of patterns of breakdown with regard to how operators and organizations manage goal conflicts, monitor work progress, recognize weak signals, align goals across teams, and adapt plans on the fly. The recursive accident representation brings together several organizational issues (e.g., the dilemma of autonomy versus compliance, or the interaction between structure and strategy) and addresses how operators adapt to challenges in their environment by adjusting their modes of functioning and recovery. Finally, it facilitates the transfer of knowledge from diverse incidents and near misses within similar domains of practice.