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The above definition given by different authors can help us to understand the word “risk” properly. From the very beginning we are surrounded by risks, if there is human then there is a risk. Our view has changed drastically with time, until the first decade of 18th century we believed that disaster were Natural and risk are directly associated with human activities but this idea changed after mid-19th century, accidents started relating with technological systems,i.e instruments/machine made by humans. According to WHO report, each year more than 1.25 million peoples die because of ⁠ road accident. Accidents happened not only due to involvement of people but also due to human made System failed. Failures started getting complex, people didn’t have any idea of the technology being used to do work. Accidents decreased when people understood the tools and artefacts they used.


In the opening of this article the author has nicely introduced the topic, by providing some historical data .he is very much interested in making us understand that the complete phenomena of Risk.

Risks are part of our life, hence we need to deal with them, but it is important to do in right way. “A risk is deemed to be large if either the loss is Severe, if probability is low, or both together. Similarly, a risk is deemed to be small, if the probability is low, or both together” (Hollnagel E. , 2008).people don’t want negative outcomes, so they are interested in finding solutions to avoid these outcomes. According to him it is very critical to identify and manage risks, so understanding the risks is first priority.


In this section of the article the author talked about the risk in different cases, he has taken examples to show how we see the problems in different ways. “Safety can be defined as the absence of adverse outcomes (accidents, incidents, personal injuries, work loss days etc.) or as a state in which the risk of harm to persons or of property damage is reduced to, and maintained at an acceptable level.” (Hollnagel E. , 2008).effective risk assessment depends critically on the ability of investigators and analysts to imagine what can possibly go wrong. This ability, or requisite imagination comprises three steps(Adamski & Westrum,2003).the first step is to understand what the problem is, second step is to understand the mechanisms and the third is to protect against consequences. If anyone or more of these fails then the risk may be high. Smoking and cancer is an example of uncomplicated risk, everyone knows the simple mechanism that tobacco smoking increases the risk of lung cancer but Global Warming is an example of complicated risk, there are still many people, writers, scientist who don’t believe in existence of global warming. We were unknown to the concept of global warming until it was represented by Swedish scientist Svante Arrhenius in warming is an example of risk that is very difficult to understand.


It is our way of thinking a risk as a large or small one. The risk is large if more lives and property are expose but it is small if the quantity is less. In the authors’ view, The probability of a risk as being large or small depends on its he said ,it’s very difficult to understand what the problem is ,or sometimes even to see that there is a problem at all-at least not until something is happened. “Adverse outcomes are not always due to cause-effect chains or a linear propagation of the effects of a malfunction, but may also arise from unusual combinations of conditions that involve poorly understood characteristics of the socio-technical system” (Hollnagel E., 2008).

Here he has highlighted the possibility of risk always exist, even if the risk of a system have been fully understood at one point in time ,this won’t be sufficient to guarantee a safe state in the future.

The improvements in the socio-technical system has contributed more towards complex nature of risk.


In this section of the article author hollnagel focused on the ideas and findings of perrow, the study of this paragraph is all about perrow’s explanation on Accidents and risk in different types of accident. “Accidents were an inevitable part of using and working with complex systems, hence it should be considered as normal rather than rare occurrences” (Perrow, 1984).Perrow has proposed two dimensions to characterise different types of accidents: interactiveness and coupling. According to Perrow, Complex systems were difficult to understand and comprehended and were furthermore unstable in the sense that the limits for safe operation were quite narrow (Perrow, 1984).

“Coupling can be defined as the subsystems and/or components that are connected or depend upon each other in a functional sense” (Perrow, 1984).through his coupling-interactiveness diagram perrow tried to explain the nature of risks and adverse outcomes of a system in different conditions.

To study different risks factor we need to go through different risk model, as a particular model can be used to account for certain types of risk not for all, e.g. Domino model (Heinrich, 1931).


The objective of study is to understand the necessity of risk assessment method. Sometimes we avoid events that are very rare and irregular (Westrum, 2006), thus makes it very difficult to determine the unusual consequences and likelihood effort to cope it. It’s very difficult to know how to respond without a clear focus, and lack of understandable cause. We can’t avoid anything when we talk about safety simply because of low probability of risk or the incidents are very rare, or never for better risk assessment we need better models and methods that are capable of explaining adverse events arise due to normal performance variability and from failures and malfunctions. The three steps of risk assessment, i.e finding the problem, understanding the mechanism and finding effective means, is applicable in both linear and non-linear accidents types.


In this part, author discussed the invention of new methods and models for Risk he said, most of the methods were developed in 1960s to match the growing complexity and growing risk, of technological systems. These methods are still being used for risk analysis and investigation. Some of them are ICBM (cf. Leveson), HAZOP (cishc 1977), and FMECA (std-1629, 1980).

“As human factors and errors played a significant role in system safety, hence it was necessary for risk assessment and accident investigation to look beyond the technological system” (Hollnagel, 2008).

Hollnagel has mentioned some of the major changes and developments took after the 1990s:

  • An increasing emphasis of the organisational factor, spurred by Jim Reason’s book on organisational accidents (Reason, 1997)
  • the increasing importance of software (e.g., the concept of Safeware; Leveson, 1995),
  • the emphasis on high reliability organisations, (e.g., Weick, Sutcliffe & Obstfeld, 1999)
  • the changing perspective on causality, moving from sequential models to systemic models (Hollnagel, 2004),
  • the associated change in view on “human error”, from the “old” look to the “new” look (Dekker, 2006),
  • the change from training in specific skills to training in general communication and collaboration (Helmreich, Merritt & Wilhelm, 1999),
  • the change from reactive to proactive safety, as marked by resilience engineering, (Hollnagel, Woods & Leveson, 2006)

“The growing complexity of socio-technical systems has also necessitated the development of more powerful accident investigation and risk assessment methods and a revision of the underlying analytical principles” (Hollnagel, 2008)


There was a need for something better to deal with the problems, so new methods were developed to account for novel types of accidents and incidents. New methods can focus on a specific, salient factor of an event, or they become more comprehensive by trying to draw together collective experience and changes. According to the various accident investigation and risk assessment methods can be characterised in terms of the assumption they make about the nature of risks.


The followings are some important risk assessment methods mentioned by hollnagel in this work

  1. Accident Evolution and Barrier Function (AEB): “it is a method that looks after the barriers and/or defences and explains accidents as the result of failed or deficient barriers” (Svensson, 2001).it describes the evolution towards a series of interactions between humans and technical system, where the interactions are represent as failures, malfunctions or errors that could lead to or did result to an accident. This method only models errors and hence
  2. HERA(Human Error in ATM),”it’s an example of a method that focuses on human error as the primary contributor to risks and adverse events”(Isaaac,Shorrock & kirwan,2002).its objective is to identify and quantify the impact of the human factor in incident/accident investigation, safety management and prediction of potential errors arising due to advancement in technology. HERA analysis mainly deals with Human errors and Violation.
  3. Root Cause Analysis (Wilson et al., 1993): the objective is to identify the deficiencies in a safety management system that, if corrected, would prevent the same and similar accidents from is a systematic process that uses the facts of the accident to determine the most important reasons or causes.
  4. “HINT” (Takano, Sawayanagi & Kabetani, 1994), it is generally the Japanese version of the “Human Performance Enhancement System” (HRES; INPPO, 1989).the overall principle of HINT is to make a root cause analysis of small events to identify trends, and to use this as basis for proactive prevention of accidents.
  5. SCM: “it is one of the best known accident investigation models of the 1990s,known as Swiss cheese model”(Reason,1990).it represents an organisation’s protection against failure as a series of barriers, represented as slices of Swiss cheese.
  6. MTO (Man-Technology-Organisation): “it especially considers how human, organisational, and technical factors can interact to build a risk, and therefore also serve to explain accidents that have happened” (Bento, 1992; Rollenhagen, 1995).
  7. CREAM (cognitive Reliability and Error Assessment Method): “it was developed to be used both predictively and retrospectively” (Hollnagel, 1998). Unlike the Swiss cheese and the MTO approaches, it has a clearly derived theoretical concept in the Contextual Control Model (COCOM). This emphasises that risks are a function of the degree of control in a socio-technical system, and connects the degree of control with four different modes (strategic, tactical, opportunistic, and scrambled). A lower degree of control corresponds to less reliable performance. The level of control is mainly determined by external factors rather than by internal failure probabilities.
  8. STAMP (System-theoretic model of accidents):”it is a useful way to analyse accidents, particularly system accidents (Leveson, 2004).this model explains, Accidents occur when external disturbances, component failures, or flawed interactions among system components are not properly handled by the control system.
  9. FRAM(Functional Resonance Accident Model: “it provides a way to describe outcomes using the idea of resonance arising from the variability of everyday performance”(Hollnagel, 2004 & 2012).developing methods for accident investigation and risk management that describe system functions rather than components or structures can be achieved by using functional resonance instead of causality,and by using normal performance variability instead of malfunctioning.

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