When investigating adverse events, “has the pendulum swing too far” towards remote and abstract organisational factors and away from local conditions. Among helping to popularise organisational & system approaches to understanding safety and unsafety, James Reason also questioned the extent of chasing latent and upstream factors versus downstream worksite factors. [Note. I present this more… Continue reading Has the pendulum swung too far in investigations and safety?
Author: Ben Hutchinson
The contribution to design to accidents
This explored the proportion of accidents that have design as a primary causal factor in aviation, nuclear and rail. Namely, this study sought to confirm whether the claim that 60% of accident causes arise from design stages. Note that it’s not a systematic analysis, nor the latest data, but interesting nonetheless. For methodology, when the… Continue reading The contribution to design to accidents
Examining Factors that Influence the Existence of Heinrich’s Safety Triangle Using Site-Specific H&S Data from More than 25,000 Establishments
One of several studies that explored the statistical validity of the safety triangle. Data was from >25,000 establishments over a 13-year period from the US Mine Safety and Health Administration seeking to understand whether or not the OSH incident and injuries that a mining establishment experienced influenced the probability of subsequent fatal accidents. Three research… Continue reading Examining Factors that Influence the Existence of Heinrich’s Safety Triangle Using Site-Specific H&S Data from More than 25,000 Establishments
Shifting the safety rules paradigm – Introducing doctrine to US wildland firefighting operations
A VERY interesting study. It explores the shift the US Forest Service took from seeing rules from a compliance/violation logic that people *must* obey & which apparently prescribe safe actions, to an operating philosophy where rules are instead adaptable. Here, rules are tools to expand options for actions where firefighters use judgement to selectively choose… Continue reading Shifting the safety rules paradigm – Introducing doctrine to US wildland firefighting operations
System factors “behind human error”
The below images are really just an index from the book “Behind Human Error” – but nicely summarises some key concepts. The meaning of most items are obvious but I’ll explain some of the less obvious statements. #2 about erroneous assessments/actions being heterogenous indicates that performance is contextual, so grouping everything under a neat label… Continue reading System factors “behind human error”
Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units
This study explored organisational learning by way of specific learning activities within project teams. This occurred in the context of a complex service organisation (hospital). Providing background, it’s noted that: Results Learn-what and learn-how were positively correlated, as was psychological safety and learn-how activities. Learn-what and learn-how were also positively correlated with perceived implementation success.… Continue reading Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units
Psychosocial risks and hydrocarbon leaks – an exploration of their relationship in the Norwegian oil and gas industry
This explored the relationship between a psychosocial risk indicator (obtained via survey data) with hydrocarbon leaks on Norwegian oil & gas producing platforms and whether the indicator can be used as a proactive indicator for preventing such leaks. The study also factored in the some technical issues of offshore installations, including installation age, weight and… Continue reading Psychosocial risks and hydrocarbon leaks – an exploration of their relationship in the Norwegian oil and gas industry
Using Safety-II and resilient healthcare principles to learn from Never Events
A very interesting read. This used a secondary analysis (qualitative and quantitative) of 35 Root Cause Analysis (RCA) serious incident reports (‘Never Events’) from a NHS Foundation Trust. The goal was to see if and how Safety-II/resilient healthcare principles could contribute to the quality of investigation, e.g. understanding misalignments between demand & capacity, adaptive capacity,… Continue reading Using Safety-II and resilient healthcare principles to learn from Never Events
Psychological safety isn’t trust or team coherence
Amy Edmondson discusses some nuances about what group psychological safety is or isn’t. (I’ll post further on this in the near future). 1. It’s not coherence since coherence can make it more difficult to voice dissenting views (image 1). 2. It’s also not trust, but trust is important. Trust refers to interactions between two individuals… Continue reading Psychological safety isn’t trust or team coherence
Investigating a new classification to describe the differences between Work-As-Imagined and Work-As-Done
This brief conference study explored gaps between work-as-imagined (WAI) versus work-as-done in the field during real work tasks. Six workers at a petrochemical facility wore helmet mounted cameras and recorded undertaking filling operations. The video was then used to compare work practices against written process and coded using the WAI / WAD framework shown below:… Continue reading Investigating a new classification to describe the differences between Work-As-Imagined and Work-As-Done
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