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|Title:||Negotiated risks : the Estonia accident and the stream of bow visor failures in the Baltic ferry traffic|
|Series:||Acta Universitatis oeconomicae Helsingiensis. A, ISSN 1237-556X; 300|
|Year:||2007 Thesis defence date: 2007-05-16|
|Discipline:||Organization and Management|
|Index terms:||decision making; kriisi; laivaliikenne; merenkulku; navigation; negotiation; neuvottelut; organisaatio; organisaatiokulttuuri; organization; organizational culture; päätöksenteko; risk; risk management; riski; riskienhallinta; shipping companies; varustamot|
|Bibid:||374609 | Availability info (Aalto-Finna)|
|Abstract (eng):||This doctoral dissertation explores the social and systemic processes that led to the capsizing of the passenger ro-ro ferry Estonia in the early hours of September 28, 1994 in the northern Baltic Sea. Before this inquiry it was known that the direct cause for the vessel’s sinking had been a bow visor failure and that there had been several earlier visor incidents in the Baltic ferry traffic without raising much concern inside the shipping industry. Hence, the starting point for the study was that the Estonia accident was not a separate failure but rather a culmination point for earlier safety problems in the Baltic ferry traffic. Another guiding idea was that the development of the accident cannot be separated from how risks have generally been perceived, handled, and regulated in shipping.
The attention in the study is widened from the accident itself to the surrounding social and institutional system in which it took place. Attention is directed to the shipping industry’s cultural and social structures and sustained behavior patterns, which promoted risk taking and the tolerance of visor problems. In the analysis the empirical data by the Investigation Commission of the Estonia accident is reinterpreted through a sociocultural framework. Also interview and other document material are analyzed.
The Estonia accident is found to be a systemic failure. It is explained how the established roles of the shipowners, the shipbuilders, the mariners and the regulatory agencies promoted the free flow of traffic, affected the perception and handling of the bow visor risk, and prevented a wider negotiation of this risk within the shipping industry. More, it is explained how the customs of shipbuilding, the general tolerance for failure, and the customs of the vessel trade promoted the local negotiation of the visor risk, thus preventing learning and regulatory development at the industry level.
The new interpretation of the Estonia tragedy and its background broadens the current understanding of the development of organizational and technological failures. So far we do not have many empirical studies in social science revealing how safety results from trial-and-error type of learning over long periods of time, and how social and cultural structures may distort industrial systems towards error inducement. Particularly, the significance of the findings from the case of visor failures in the Baltic ferry traffic adds new dimensions to the literature that explores how social context affects risk perceptions and the handling of risks in everyday life. Hence, the findings can be extended far beyond the case in focus.
|Thesis defence announcement:|
University of Tennessee, USA