Do your investigations often conclude when you’ve identified ‘human error’, or a pesky person not following rules? Do you want to improve the quality and depth of your learning opportunities? One way is via local rationality: understanding why decisions & actions made sense to people at the time. It’s a core feature in human factors… Continue reading 25 questions for better incident investigations // HOP / Safety-II (YT Quickisode)

“Carefully adjust the appropriate valve until the pressure is normal” On the surface this may seem like a standard instruction, but so many important details are missing. Like: ·       Which valve? ·       Adjust it how? ·       What pressure is ‘normal’? ·       How would the operator confirm success? Will it be obvious? Some procedures and SOPs… Continue reading How can you create better procedures? Part 1

Can the same injury rate tell two different safety ‘stories’? What’s hiding in your story? An interesting read from Kevin Geddert, Sidney Dekker and Drew Rae who explore how injury measures generate different meanings and their consequences. They also discuss the use of SAIF – which is Severity Adjusted Injury Frequency (a weighted combination of… Continue reading Injury rates tell an incomplete story, but a more complete measurement narrative may be possible

Why are so many procedures technically accurate, but barely workable in practice? In part 1 of this two-part YouTube series on procedural systems, we unpack the technical side of writing better, more useable procedures: exploring how to reduce safety clutter, choosing the right type of rule, and structure instructions so they support work. We unpack:… Continue reading Writing better rules: YouTube part 1

Did you check out yesterday’s YouTube vid on ‘investigating’ when nothing failed? I quickly discussed a Safety-II / HOP -inspired debrief tool which helps facilitate insights about real work – challenges, adaptations, sources of success (and failure), variability, and more. Check it out and let me know what you think – vid link in comments.… Continue reading A Safety-II / HOP debrief tool

We focus a lot on learning from incidents, but are some of the best opportunities hidden inside work that went, apparently, successfully? In this Safe As Quickisode on YouTube, just 7 mins of your life, we rapidly unpack a healthcare study that used a Safety-II / HOP inspired debrief to learn from daily work, not… Continue reading Learning When ‘Nothing’ Goes Wrong: a Safety-II/HOP debrief tool (Quickisode)

We can learn a lot from incident, but we need to ask better questions. In part 1 with Dr Linda Bellamy, Linda explains why incident investigations should move past a human-focus and unpack: a. the barriers/controls that failed b. the task needed to maintain or use that barrier c. the conditions shaping the task d.… Continue reading SIFs, barrier & safety system failures & learning: Pt 1 with Dr Linda Bellamy