This Master’s thesis from Andrew Barrett explored group learning practices, like learning teams, for safety improvement. Specifically, he studied the following question via institutional ethnographic interviews: · how are organisations in Australia adopting group learning practices for safety improvement? Way too much to cover – so check out the thesis. Some background extracts: · “Safety… Continue reading The rise of learning teams: How organisations in Australia are adopting group learning practices for safety improvement
Author: Ben Hutchinson
Mini-Compendium: Investigations & Corrective Action Limitations / Bias / Underreporting
This compendium covers a few elements of investigations, investigation limitations and biases, priming, underreporting and more. Because of the breadth of these topics, this sample is pretty limited and biased to my own interests and what I’ve either written about or could find a full-text link for. It also doesn’t cover many investigation methods (if… Continue reading Mini-Compendium: Investigations & Corrective Action Limitations / Bias / Underreporting
“A natural consequence of punishing failures is that employees learn not to identify them, let alone analyze them, or to experiment if the outcome might be uncertain” Amy Edmondson on ‘failing intelligently’
Another extract from an upcoming summary from Mark Cannon & Amy Edmondson about ‘failing intelligently’. They talk about the various technical, social and structural barriers for organisations to effectively learn from small & large failures. In this section they zero in on the individual and manager-levels: · “Even outside the presence of others, people have an… Continue reading “A natural consequence of punishing failures is that employees learn not to identify them, let alone analyze them, or to experiment if the outcome might be uncertain” Amy Edmondson on ‘failing intelligently’
Resilient Procedures: Oxymoron or Innovation?
An interesting chapter from the late Bob Wears around ‘resilient procedures’. I’ve skipped heaps. They specifically explore: · what baggage tends to accompany procedures · what is bad about procedures · what is good about them · how procedures might be designed to support or even enhance resilience, instead of degrading it. Procedures are said… Continue reading Resilient Procedures: Oxymoron or Innovation?
Tight coupling, interactive complexity and an operator zigging instead of zagging known only in hindsight: Charles Perrow
Some wisdom from Perrow’s awesome Normal accidents. This book is full of nuggets, so just some random extracts: · “But if … the operator is confronted by unexpected and usually mysterious interactions among failures, saying that he or she should have zigged instead of zagged is possible only after the fact” · “Before the accident no one… Continue reading Tight coupling, interactive complexity and an operator zigging instead of zagging known only in hindsight: Charles Perrow
Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
This study unpacked what investigators look at and how they construct causes in high-speed workboats. It employed a Safety-II / HOP / HF perspective. Tl;dr: human factors are poorly evaluated and largely seen as individual-level factors. Some extracts: · “Although the analysis focused on negative observations, it also identified HFs that supported the activity” · “Many pivotal… Continue reading Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
The mixed blessing of risk defences and redundancy: James Reason
A few random extracts from James Reason’s timelessly awesome Managing the Risks of Organizational accidents. (Note: This isn’t an endorsement of the somewhat linearity of defences-in-depth, since we have evidence that emergent behaviour can playout in reality and with equifinality etc) There’s hundreds of things I could extract (and maybe will in time), but here’s… Continue reading The mixed blessing of risk defences and redundancy: James Reason
Above the line, below the line – Richard Cook on complex systems failure and recovery
A cool paper from Richard Cook about internet/software failures and complex systems. I’m not a software person – but still found it pretty interesting. ** Parts 2 & 3 in comments ** Just a few extracts: Ref: Cook, R. I. (2020). Above the line, below the line. Communications of the ACM, 63(3), 43-46. Shout me a coffee… Continue reading Above the line, below the line – Richard Cook on complex systems failure and recovery
Efficacy and Understanding of the Safety Hierarchy of Controls
This PhD thesis from Stephen Young was interesting. They studied evidence supporting the hierarchy of control (HOC), constraints on its efficacy, and more. Way too much to cover. Some extracts: · There isn’t a lot of evidence supporting the efficacy of the HOC · One reason is: “An unequivocal demonstration of efficacy [of the HOC] is problematic,… Continue reading Efficacy and Understanding of the Safety Hierarchy of Controls
“I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
“Every intelligent system makes errors”, so said Gerd Gigerenzer. Here’s a couple of page extracts from a 2005 paper. Not sure if I’ll summarise it or not (it’s really interesting, but tough to capture in a summary…) The paper: · Challenges the rationalistic and normative ideal as cognition as purely a logical and rational one, ignoring… Continue reading “I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
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