The Weekly Reflektion 40/2026
The drive to become more efficient is a challenge in many organisations. More done with less people, application of new technology and new methods, flat organisations, shorter communications lines, empowerment, are just some of the ways in which the organisation can ‘function’ more efficiently. Productivity is better, costs fall, competitivity improves and profits increase. However, sometimes the organisation becomes unstable and once the instability sets in, the consequences become uncertain. You may be on the road to an accident, or Major Accident.
Where is the tipping point for your organisation?
In 2008, Yuki Sugiyama and colleagues conducted an experiment using 22 cars on a 230-metre circular track. Drivers were asked to travel at approximately 30 km/h while maintaining a safe distance from the vehicle ahead. There were no junctions, traffic lights, lane changes or physical bottlenecks. Initially, the traffic flowed smoothly. Gradually, however, small variations appeared. A driver would slow slightly, perhaps because the distance to the vehicle ahead had reduced. The following driver responded by slowing too. Rather than disappearing, some disturbances became larger as they passed from vehicle to vehicle. Eventually cars were stopping and restarting, and a recognizable traffic jam had formed. Remarkably, the congestion travelled backwards around the circuit while the cars themselves continued travelling forwards. The experiment demonstrates an important principle for major accident prevention: a system can become unstable even when no individual component has suffered a major failure or any of the people involved are incompetent or inexperienced. Later circular-track experiments explored different vehicle numbers and densities and showed that there seemed to be a tipping point where the traffic jam did not occur. This point depends on vehicle density, spacing, speed, driver response and other parameters.
Similarly, the tipping point for when an organisation fails to respond properly is unknown. Changes are implemented and often the management of change (MOC) process is superficial or even non-existent. The people find a way of making things work but traffic jams occur and things are not quite as smooth and systematic as they were before. Disturbances that previously did not affect the flow, suddenly create instability and uncertainty. Incidents and accidents increase and the safety of the operation is affected.
In the traffic experiment, eliminating careless drivers would not necessarily eliminate congestion. Human variability is unavoidable. Similarly, an operation cannot be designed on the assumption that equipment will never fluctuate, instruments will never drift, operators will never hesitate and operating conditions will remain exactly as planned. Before the organisational change these fluctuations did not escalate into an unsafe condition, after the organisational change things are different. The margins are eroded, resilience is reduced and instabilities occur.
This awareness is also important in investigating incidents that haveorganisational causes. When we ask the traditional investigation question, “What caused the accident?” it may encourage us to search for a single initiating event. Sugiyama’s experiment suggests another question: “Why was the system capable of amplifying such a small disturbance?”
The objective of major accident prevention should therefore not simply be to prevent large failures. It should be to identify and control the conditions in which small, ordinary disturbances can combine, propagate and grow into something much larger.