3.0. Management System

The importance of the management system in controlling risk/losses is visualized in the picture below. This picture represents the incident causation sequence that comes from the work and thinking of Heinrich and Bird. I have given my own thoughts to it and so arrive at the TOP model - Total Operations Performance. 

The basic thinking behind the model is that the management system, containing the control activities (MAA's), creates the basic causes that exist in the organization. These basic causes then produce the direct causes (acts and conditions) that lead to the undesired event(s). Those may or may not result in initial loss, depending on circumstances and barriers  that may or may not be present. The final loss then depends on the emergency remedial actions that are taken, or not. (PEP stands for Post Event Plan and comprises all the actions to reduce various (material or immaterial, direct or indirect) losses that may result from the incident, including also business or consequential losses.) 

People related issues are vital to the total sequence. These issues are either permanent of temporary. They may be deficient (or "sub-standard") or they may be proper (or "standard").

If they are permanently deficient they lead to imperfect organizational or production systems, imperfect technical systems and continuing sub-standard behavior of managers, supervision, staff  and other employees.  Deficiencies are "built-in" and the only thing one has to do is to wait to see that the risk materializes into loss. 

If the people issues are temporarily deficient, they should be seen as deviations from an otherwise accepted or "perfect" way of doing things. Even though they are temporarily, they can lead to permanent deficiencies in technical or procedural controls and if these deviations - or their results - are not spotted early enough or if no action is taken following their recognition, losses may still occur.  

I have provided multiple layers throughout the sequence (with the exception of the management system box) to indicate that there is often more than one issue involved.  Two-dimensional models may, for example,  give the impression that only one person is involved while in practice a number of people have played their role in the incident causation sequence. For example, it may be the act of the person directly involved in the execution of the work that triggered the incident resulting in loss. However, that person may not have been trained properly (= act of supervision/management) to do the work or it may have been the purchaser who did not buy the right equipment (= act of staff person) or the designer who did not construct the work environment properly (= act of staff person). Or it may have been the manager who did not assure that the purchaser was buying the right stuff and the designer was following state of the art criteria (= act of manager).  For the same reason, I provided a loop back from "Direct causes" to "Basic causes" - the (even temporary) sub-standard act of the designer (following improper motivation, for example)  may lead to permanent sub-standard conditions waiting for the incident to occur.

The above model is negative in the sense that all aspects are below standard to produce loss at the end. Alternatively, the model can also be put in a positive mode to produce success in the end box. To arrive at that desired situation all the other issues in the model must be positive to create an organization that knows its risk and has taken appropriate actions to control them. On top of that the organization will have installed appropriate instruments to uncover deviations from the normal (= safe/non-risk ) situation in order to take appropriate actions before those deviations can result in undesired loss.

So, the management system is important. Now what makes the management system really a system of management are basically two things:

	what activities and attention areas (MAA's) are contained in it
	the structure in which the activities are brought to make sure that work is done and results obtained

Further information on these two aspects can be obtained through:

System Intro

While the management system structure should stimulate implementation of activities towards success, evenly important is the process that leads to the development and implementation of the management system. That process is further discussed under:

Implementation