Operational Risk in Incident
a Cross-fertilisation between
ISCRAM and IT Governance
Gerd Van Den Eede (Vlekho Business
Bartel Van de Walle (Tilburg University,
Research questions (1)
Fine-tune the research
methodology on risk identification
based on cognitive mapping
techniques and group decision
support systems (GDSS)
developed earlier (Rutkowski et
Research questions (2)
Determine how High Reliability
Theory (HRT) can be applied
in the particular organisational
context of an important
economic sector like banking.
Research questions (3)
How can Information Systems for
Crisis Response and
Management benefit from
experiences gained in a
Infrastructure Library (ITIL).
Innovation and efficiency (80s and 90s)
Risk control and effectiveness (00)
Flexibility < > Reliability
Adhocracy < > Bureaucracy
• Basel II
incl. operational risk
• Sarbanes-Oxley Act
protection of the (small ?) American
avoidance of fiascos
Research Question 1
van Groenendaal W. &
Van de Walle B.)
(Pre)structuring of information
Example of an interview question:
“What is the most dramatic event you can
recall during which business processes
came to a halt and where incident
management did not sufficiently succeed
in restoring the normal situation?”
Participant‟s X view on Risk
- Combined mental model
- Shared view on risk
- Risk assessment
- Determination of Risk Response
A list of prioritised operational risks, fully
assessed in terms of importance incl. the
Formulated as an advice to the line
Research Question 2
High Reliability Theory (HRT)
High Reliability Organisations (1)
“how many times could this organization
have failed resulting in catastrophic
consequences that it did not?” If the
answer is on the order of tens of
thousands of times the organization is
„high reliability‟.” (Roberts)
What explains this success?
High Reliability Organisations (2)
- Emergency services
- Military applications (aircraft carriers,
- Oil platforms
- SWIFT, BP
High Reliability Organisations (3)
HRO (La Porte, Roberts, Weick, …)
Normal Accidents (Perrow)
High Reliability Organisations (4)
Berkeley (University of California)
University of Michigan
High Reliability Organisations (5)
- Continuously reinventing oneself
- Flexible „improvisation‟ on existing
- Decision making on each level of the
- Strong culture: open communication,
easily accessible hierarchy.
High Reliability Organisations (6)
- Sense Making
all participants dispose of a different
part of the information/knowledge.
Together they can put together the „big
HROs deal with crises effectively and efficiently.
“operations are sustained or resumed (i.e. the
organisation is able to maintain or regain the
momentum of core activities necessary for
transforming input to output at levels that satisfy
the needs of key customers), organizational and
external stakeholders losses are minimized, and
learning occurs so that lessons are transferred
to future incidents” (Pearson).
= double-loop learning: changing procedures,
objectives, norms, processes and strategies.
Reliability vs. Flexibility
A role for Sense Making
What is Sense Making? (Nathan)
1. Identity constructing
6. Cue Extracting
7. Plausibility, Not accuracy-driven Skip
Swiss Cheese Model
Goal Conflicts and Double Binds
Incomplete Inadequate Deferred
Procedures Messages Training Attention Maintenance
Production Distractions Clumsy
Modified from Reason, 1991
1. Identity constructing
• The organization seeks to discover what it
“thinks” and “knows” about itself and its
• Identity construction is the basis for
imparting meaning to information inside of
an organization, and, eventually,
• determining what problems must be
• Sense making is an examination of past
• in order to learn (and unlearn) things
• about the current context.
• There is no objective environment out there
separate from one‟s interpretation of it.
• Thus, the organisation creates or enacts parts of
its environment through selective attention and
• Interpretation can shape the environment more
than the environment shapes the interpretation.
• We act and actions become part of the
environment that then constrains future actions.
The subsequent action tends to confirm
• Cognitive and social aspects of sense making
are inextricably linked. Other people are integral
to our efforts to make sense of things because
what we say or think or do is contingent on what
others say and think and do.
• Even if we are alone, we imagine the response
of others to our actions or thoughts, and adjust
our thinking and behaviour accordingly.
• Sense making requires talking, interaction,
conversation, argument, and dialogue with
others. Links or bonds are created through
• Most of us at any given time find ourselves “in the middle
of something.” As we move from one situation to
another, we make and revise assumptions and beliefs
along the way. Our sense making is ongoing. It has no
real beginning and no formal end.
• We work at making sense of past events to develop a
story that we understand, and as future events unfold we
revise our story.
• Sense making takes place in a continuing and dynamic
fashion as events unfold and we continually seek to
understand what events mean in relationship to our
6. Cue Extracting
• Sense making is focused on and by extracted cues. We
notice some things and not others. We pay attention and
extract a particular cue, then link it with some other idea
that clarifies the meaning of the cue, which then alters
the more general idea to which we linked the cue, and
on and on.
• The cues we extract from situations tend to be simple
and familiar and are crucial for their ability to get us
moving. While moving, we keep noticing other areas and
we stop to update our understanding as we go along.
• These extracted cues enable us to act, which increases
our confidence and confirms our faith in earlier cues. In
essence, we decide what to pay attention to.
7. Plausibility, Not accuracy-driven
• Looking for what is plausible is often of more
practical help then finding accuracy. Totally
accurate perception is not needed, which is
good because what is needed is that which is
plausible and reasonable.
• Plausibility helps us explore what we see and
energizes us to act. The search for accuracy on
the other hand, can de-energize us as the
search drags on and on.
Research Question 3