I found this paper interesting – it evaluated the likelihood of a run of poor outcomes (mortality during surgery). Although it focuses on surgery, I think we could take lessons from the probabilities about runs of incidents in any other industry (e.g. construction incidents) – and the problem of knee-jerk reactions to statistical random variability… Continue reading Chance of runs of workplace accidents: How likely is it that a run of poor outcomes is unlikely?

I found this 1990 paper from Wagenaar, Hudson and Reason interesting (more from the historical perspective); but still pretty insightful. Note. Don’t read into the specific findings, nor the language used (e.g. “foolishness”) too much – it is >30 year old, after all. Some points covered: ·        Safety awareness initiatives tend to be among the most… Continue reading Cognitive failures and accidents

This meta-analysis explored the link between work injuries and mental health challenges. Providing background: ·       A large number of people “endure preventable work injuries and manageable mental health conditions”, and these issues are compounded by “widespread underreporting, driven by fears of repercussions, insufficient workplace accommodations, and complex reporting processes” ·       There’s limited consensus regarding the… Continue reading Work injuries and mental health challenges: A meta-analysis of the bidirectional relationship

This brief paper from Hollnagel & Macleod may interest you. Some key points: In sum, they answer three questions: Ref: Hollnagel, E., & Macleod, F. (2019). The imperfections of accident analysis. Loss Prevention Bulletin, 270(3), 2-6. Study link: https://www.icheme.org/media/12669/lpb270_pg02.pdf My site with more reviews: https://safety177496371.wordpress.com LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_this-brief-paper-from-hollnagel-macleod-activity-7200975055361613824-PTT1?utm_source=share&utm_medium=member_desktop

This study unpacked three workplace events, comparing each organisation’s investigation report to the researcher’s own evaluation from a cognitive trap (error trap) perspective. Note: I translated this from Portuguese via Google, so there could be mistakes. Providing context they note: ·         Criticism has emerged against “concepts that presuppose the existence of direct relationships between failures,… Continue reading Cognitive traps: the case of omissions in the genesis of work accidents

What proportion of chemical process incidents have design as a contributor? This study soon to be summarised explored these links. They analysed 284 major equipment-related accident cases from a database. What I liked about the definition of design in this study is that it went beyond just the literal plant/equipment view. Here, a “design error… Continue reading The role design error plays in chemical industry accidents

What is the relationship and directionality between work injuries and mental health challenges? That is, are work injuries more likely to precede mental health challenges or vice versa? This upcoming summary meta-analysis evaluated these links. Key findings: ·        There’s a consistent and modest link between work injuries and mental health challenges ·        The relationship is stronger when… Continue reading Are work injuries more likely to precede mental health challenges or vice versa?

A fantastic read from Gemma Read, Steven Shorrock, Guy Walker and Paul Salmon discussing the history of core theories and methods over the last 60 years around ‘human error’. Also discussed was the human error construct within ergonomics & human factors (EHF), some “key conceptual difficulties” that the human error construct faces in a systems… Continue reading State of Science – Evolving Perspectives on ‘Human Error’

Another paper from the Barry Turner files from 1999, reflecting on the then 20 year period since Turner published his seminal work (this paper was written after his passing). Based on Turner’s analysis on the incubation of disasters: ·        Rigidities in perceptions and beliefs about what is and isn’t counted as a hazard. For instance, at… Continue reading Man-Made Disasters 20 years later: critical commentary

This study explored the shift from a punitive to non-punitive reporting approach in a hospital over 2 years, while assessing the capacity and success of learning. Before the transition, an employee involved in an incident reported the event to his/her manager, who would then devise improvements (mostly in the form of a reminder to watch… Continue reading From punitive action to confidential reporting: A longitudinal study of organizational learning