The crucial role major incidents play in risk management

George Spafford wrote at about Control and Process Reviews. His article highlights the crucial role the major incident process play in risk management. It is a trigger for control and process review:
"In response to a variety of needs including process improvement and regulatory compliance, organizations develop controls and processes. Many times they are aimed at preventing an error from happening again. The problem is that there is a constant need to evolve. If processes are not updated, then they can slow or even halt progress and create conflict. A trigger for correction is major incidents. A review should be conducted after each crisis to learn if the policies, processes and/or procedures need to be revised. If so, then a request for change should be submitted, the necessary changes should be made and then submitted for review and approval through the Change Management process."


  1. Found this looking for a picture of an AHU, thank you Google.
    Major incidents play a crucial role in the development of legislation, especially in the safety field, consider the presence of specific design and test requirements in the areas of pressure and instrumented protective systems. Building regulation and design codes are built from analysis of failure in many cases. The area where I work, protection of workers from exposure to hazardous chemicals is less well defined outside of specific OSHA/HSE exposure levels (limited list) partly I believe because the impact of these exposures are in many cases chronic and may not become evident for several decades. To be taken seriously you need an event that causes immediate, ideally large scale, visible effects.

  2. Thanks for reading.

    Your opinions are correct and given the lack of transparency in IT, it has the same issues as what you have described.

    I believe that many industries would benefit from FAA type equivalents. (Something to blog about!)


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