SafetyInsights.org

For those interested, the attached image is an AcciMap from Andrew Hopkins on the Glenbrook train crash.

What I like about AcciMap (and STAMP/STPA, FRAM etc.) is its focus on articulating the connections between factors and its structural focus on different hierarchical levels (e.g. not just the individuals or workplace, but also upstream beyond the organisation to society).

Here, Hopkins has divided the crash into different causal categories:

1. Specific causes:

·        Things like failure to drive with extreme caution

·        the driver’s belief that the track was clear

·        inadequacy of an important rule

·        archaic phone technology

·        signal failure

·        etc.

2. Cultural causes: (hint – use the word “culture” loosely here)

·        Culture of on-time running

·        Culture of silos in and outside of the business

·        Risk-blind culture

·        Culture of rules

3. Sources of culture:

·        Public Pressures

·        Disaggregation (state rail authority divided into three separate entities)

·        Occupational Isolation

The good thing about any incident or work/task analysis or mapping exercise is that you don’t need to wait for bad things to happen to learn.

All of these methods work just as well to learn from normal, everyday work and the (convoluted) network/paths towards desirable or non-desirable performance.

Source: Hopkins, A. (2005). Safety, culture and risk: The organisational causes of disasters. CCH Australia.

Link to the LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_for-those-interested-the-attached-image-activity-7058934628178395136-dY5U?utm_source=share&utm_medium=member_desktop