Leveson & Cutcher-Gershenfeld discuss systems safety in the context of the Columbia Accident Investigation Board (CAIB) investigation. NB. These types of analyses are, of course, replete with hindsight and outcome logics, and sometimes judgmental attributions (failure, inadequate). But that doesn’t inherently mean we can’t learn anything. Extracts: · “The CAIB report describes system safety engineering at… Continue reading What System Safety Engineering Can Learn from the Columbia Accident (Nancy Leveson)
Year: 2025
The safety measurement problem revisited
A response from Kjellén to Hopkins’ 2009 article about indicators (link in comments). [See week’s compendium dedicated to Hopkins & Hale] Extracts: · “LTI-rate gives the same weight to injuries with dramatically different consequences; that the measure is easily manipulated; and that natural statistical fluctuations make it useless for feedback control of other than the largest… Continue reading The safety measurement problem revisited
Leveson and Dekker on Reason: How the Critics Got the Swiss Cheese Model Wrong – Andrew Hopkins
Andrew Hopkins in this article defends Reason’s Swiss Cheese Metaphor (SCM) from critiques from both Nancy Leveson and Sid Dekker. Just a few extracts. [** Be on the lookout for next week’s compendium dedicated to Hopkins & Hale] I’m taking no sides – just reporting what’s in the paper: · He selects criticisms of Reason’s work… Continue reading Leveson and Dekker on Reason: How the Critics Got the Swiss Cheese Model Wrong – Andrew Hopkins
Importance of understanding work-as-done: Fascinating extracts from CEO due diligence prosecution
Understanding work-as-done seen as critical for PCBUs and CEOs/Officers, according to this prosecution of a CEO who failed to exercise due diligence relating to a work-related fatality (Ports of Auckland Limited (POAL). Extracts: · “[234] “Work as done” is the reality of work as it is actually carried out by the workers on the shop floor.… Continue reading Importance of understanding work-as-done: Fascinating extracts from CEO due diligence prosecution
Rail suicide: A systematic review using systems thinking
This systematic review evaluated rail suicide research against the systems thinking techniques AcciMap & PreventiMap. Some extracts: · “In Australia, 67 suicides by train occurred across 2019–20, representing 80 % of all fatalities occurring on the railways” · “Rail suicide is distinct in that in addition to the person who dies by suicide [and the familiy/friends affected],… Continue reading Rail suicide: A systematic review using systems thinking
“A good leader and a conscientious officer may have the best intentions in the world but may still breach that duty”: Fascinating legal case of CEO due diligence prosecution
Fascinating read of a CEO charged for not exercising due diligence, resulting tragically from a work-related death (Ports of Auckland Limited (POAL). Posted over multiple days, as it also covers work as done, critical risks, audits, indicators, inconsistent nightshift practices and more. Starting with due diligence: · “A good leader and a conscientious officer may have… Continue reading “A good leader and a conscientious officer may have the best intentions in the world but may still breach that duty”: Fascinating legal case of CEO due diligence prosecution
“Managing the risks of major accidents” – Andrew Hopkins, YouTube presentation
A 2024 YT video from Andrew Hopkins about managing the risks of major accidents. This comes in the lead up to next week’s compendium of research dedicated to Andrew Hale & Andrew Hopkins. Some extracts: · He refers to the Safety Paradox where managers “honestly believed that safety was their top priority that they never sacrificed… Continue reading “Managing the risks of major accidents” – Andrew Hopkins, YouTube presentation
The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
“There was a very real sense in which all three parties were simply going through the motions together of producing ‘paper safety’” This is a nearly 600 page accident inquiry for the 2006 military aircraft accident – just a few extracts I found interesting regarding broader safety management. It’s a fantastic read and a masterclass… Continue reading The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models
Does the Swiss Cheese metaphor hold its own against systemic accident models? Yes, according to this study. Seems topical to share this paper, comparing the ATSB variant of a Swiss Cheese accident model vs AcciMap and CAST (i.e. STAMP). They found: · “each model applied the systems thinking approach” · “However, the ATSB model and AcciMap graphically… Continue reading Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models
Compendium: Leadership / Safety Leadership / Leaders Behaving Badly / Followership
Here’s a mini-compendium of research surrounding leadership, safety leadership and followership. NOT systematic – there’s way too much to cover in this space. Focus is on the links between leadership attributes / interventions on indices of performance. The other focus is on studies I’ve either summarised or could locate a full-text link for. ** For… Continue reading Compendium: Leadership / Safety Leadership / Leaders Behaving Badly / Followership
SafetyInsights.org 