This studied, via interview, differences between how procedure administrators (representing work as imagined, WAI) perceive the design and use of procedures versus the realities of procedure users (work as done, WAD) across several large, international chemical sites. Providing background: ·       While procedure use/departures are mentioned across many major accidents, procedure users in some data reported… Continue reading The realities of procedure deviance: A qualitative examination of divergent work-as-done and work-as-imagined perspectives

This was a fascinating read, exploring objectivist and constructivist explanations and reflections around the public inquiry into the Waterfall train accident; and namely how a myopic objectivist focus on rational decision-making and technology may lead to blame and a weak understanding of sociotechnical & social systems. I can’t do it justice. Some of the key… Continue reading The folly and blame of objectivist and rationalistic investigations – the Waterfall train accident

This explored the effectiveness of incident reporting systems (IRSs) for improving patient safety and on effectiveness on learning. The relationship between incident reports & actions were evaluated on changes in practice and whether the changes involved settings, processes or outcomes. Further, single-loop learning (correction of operational issues without significantly changing the overall structure or beliefs)… Continue reading How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

What is the relationship between reasonable tasks, clutter, and bullshit tasks in safety management? An upcoming summary explored these links, tracing the connection from regulation to internal requirements. Some points: It’s open access, so you can freely read the chapter and book. Authors: Størkersen, K. V., & Fyhn, H. (2024). In Compliance and Initiative in the… Continue reading Reasonable tasks, clutter and bullshit tasks in the pursuit of safety management

I found this paper pretty interesting. It’s from 2008 and provides a good primer on resilience engineering, defining types of systemic disruptions that our systems may encounter, and then some principles and heuristics that may be useful. It’s from the infancy of Resilience Engineering as a distinct area of focus, but still holds up to… Continue reading Towards a conceptual framework for resilience engineering

See below for a link to the Safety of Work podcast, where I discuss the implications of my two studies on safety auditing.

What is the role of safety cultural dimensions in explaining real cases of financial misconduct? Quite a lot, according to this interesting study. It’s open access, so you can read it in full yourself. They drew on cases including from JPMoran, UBS, Batclays, Credit Suisse and more. There’s heaps of findings – I’ve only included… Continue reading Safety Culture in Financial Trading: An Analysis of Trading Misconduct Investigations

A cracking read from Bob Wears and Charles Vincent, exploring how we can come to over-rely on the adaptability of people and systems. I’m using a lot of direct quotes. They note that while “resilience is generally thought of as an unalloyed good …no silver lining is without its cloud” and that in some circumstances,… Continue reading Relying on Resilience: Too Much of a Good Thing?

This interesting paper that you can read in full operationalised a complexity attribute framework, involving: (i) the delimitation of the socio-technical system (STS) (ii) the description of four complexity attributes, namely a large number of elements in dynamic interactions, a wide diversity of elements, unexpected variability, and resilience (iii) the assessment of six management guidelines,… Continue reading Complex socio-technical systems: Characterization and management guidelines

I’m re-reading Robert R Hoffman’s et al.’s excellent book “Accelerated Expertise: Training for high proficiency in a complex world” and they cited this paper (also from Hoffman et al.). It explores human-centred computing from a procurement perspective, but actually is a really cool read about human-centred design. They talk about the “trap of designer-centered design”,… Continue reading The traps of designer centred design, and the benefits of human-centred design