This paper explored the collapse of the UK construction and facilities company Carillion from the perspective of the Normalisation of Deviance (NOD). Too much to cover in this, so I’ve skipped large sections. Providing background: ·         NOD was first introduced by Diane Vaughan in her Challenger Launch Decision book ·         It occurs when “individuals within… Continue reading Normalising deviance in construction project organizations: a case study on the collapse of Carillion

Can a focus on compliance distract us from managing risk? Perhaps, according to a coronial investigation. Described in this coroner’s report was the drowning of an Operations Supervisor at an organics facility during a flash flood event. Regrettably, the supervisor was caught in an overflowing leachate drain. Some findings in this report were that: An… Continue reading Coroners report: rules not playing nicely, and too much focus on compliance over managing risk

This paper discussed 6 fallacies of biases and 8 sources of bias that influence decision making and investigations. The focus is more on forensics and the like, but still a useful read. Note that bias isn’t an inherently bad or undesirable thing. First, six fallacies of bias are presented: For ethical issues, “Many incorrectly think… Continue reading Cognitive and Human Factors in Expert Decision Making: Six Fallacies and the Eight Sources of Bias

How does project complexity influence safety, and what impact does an organisation’s capacity for resilience moderate this relationship? An upcoming summary studied the complexity/unsafety relationship and also the impact that a “resilient safety culture” (RSC) had in the construction sector. Resilient Safety Culture (RSC) is defined as “an organizational culture that fosters safe practices for… Continue reading Project complexity, unsafety and resilient safety culture

An upcoming summary explored the normalisation of deviance (NoD) in the collapse of British construction and facilities firm Carillion. NOD was first introduced by Diane Vaughan in her Challenger Launch Decision book. It occurs when “individuals within an organisation become gradually insensitive to deviant practice so that it no longer feels wrong”. NOD is typically… Continue reading Normalisation of deviance and the collapse of construction company

Another coroner’s inquest which had some interesting findings around a tragic workplace death. This related to heat-related cardiac arrest, relating to a likely +40 degree Celsius day. First, I like how the coroner’s frequently call out hindsight bias, and its effects in post-event clarity, that being “the potential to look at circumstances in retrospect and… Continue reading Heat-related work death and the abrogation of responsibility of safety to workers

This brief paper re-evaluated an accident that occurred where an operator’s arm was amputated during operation of a brake-clutch type mechanical press. The authors took a more systemic approach, unpacking cognitive traps and design/organisational factors of the event that were seen to be largely absent from the original investigation. Providing a bit of context: ·      … Continue reading Safety illusion and error trap in a collectively-operated machine accident

Do Zero Harm (ZH) / Zero Accident approaches result in criminalisation of human error? This interesting case study explored the ZH approach in a Dutch steel company. Given my prior critical posts on ZH, this will hopefully provide more nuance, as this paper takes a balanced view highlighting the positive logics of ZH, with some… Continue reading What role does zero harm play in the criminalisation of human error?

This study evaluated base-rated error in workplace safety investigations. In particular, it sought to evaluate the magnitude of professional industrial investigator’s bias to attribute cause to a person more readily than situational factors. 50 undergraduate students and 12 professional industrial incident investigators from the forestry industry: 1) read a summary of a workplace event and… Continue reading Measuring base-rate bias error in workplace safety investigators

Another upcoming summary revolves around bias in expert decision making (yes, another bias post…) I’ll probably focus more on the positive heuristics stuff after this, but I digress. Note, this paper is from a forensic science and criminal perspective, so consider in that in their use of language like ‘suspect’. First, the author clarifies some… Continue reading Fallacies and biases in expert decision making