Another absolute banger of a paper co-authored by one of my favourite authors – the late, great Bob Wears. As is often the case with Bob and co’s papers, these brief 3-4 pagers are the most densely packed and most difficult to summarise. I’m using a lot of direct quotes because the language is poetic,… Continue reading Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures

What impact does a comprehensive Crew Resource Management (CRM) training program, and subsequent practices, have on in-hospital patient mortality and failure to rescue? Not a lot, according to another upcoming study. Two hospitals, one control and one intervention, were compared after 3 years. The CRM program in the intervention hospital consisted of a 4-hr comprehensive… Continue reading Crew Resource Management training and patient mortality: no significant effects

An upcoming summary explores an organisational “imagined disease”, termed by the author as “auditism” [** I love this term]. It’s noted that we’re surrounded by auditism, and have been convinced that what we do at work must be documented, to “prove that we did what we should have done”. Auditism is said to emerge “when… Continue reading Organisational disease: auditism. A condition where ill-fitting management systems and practices are propagated

This studied the impact various management strategies to boost labour productivity have on safety. Strategies were human resource (HR) and construction management (CM) related and included a large number of strategies (48 practices; shown below).  Survey data was collected from 111 general construction projects. The importance of this is that construction is not just one… Continue reading Unintended consequences of management strategies for improving labor productivity in construction industry

An interesting read from Ivan Pupulidy describing the shift in the US Forestry Service’s approach to serious incident investigation from their prior method to that of a Learning Review. There’s a lot here (210 page dissertation), but the summary provides a useful collection of key assumptions that “bound” their thinking to less effective ways to… Continue reading Shift from human-focused investigations to system focused learning and sensemaking in US Forestry

This study explored the links between non-compliant behaviour (procedural departures but accounting for risk perception), safety climate and safety leadership. 390 workers and their supervisors in a Chinese power grid construction firm were sampled. Note: While this study talks of compliance (and associating rule following as ‘correct’ or ‘compliant’) and violations (I’ve never liked ‘violation’… Continue reading Violation with concerns of safety: A study on non-compliant behavior and the antecedent and consequent effects in power grid construction

Our recent study of 44 major or fatal accident reports in the process, chemical, pipeline, mining, oil & gas industries explored how audits failed prior to the accident (according to the investigation). In the first post (link below), I covered the first two categories of audit failures (1 Audits involve a failure to understand, 2… Continue reading Major accident audit failures p.2: A failure to manage and a failure to focus

This study explored the interactions between US miners’ risk avoidance and locus of control on near miss incidents on the job. Data was from >1.3k US miners via survey. Providing background: ·         Several theories exist attempting to understand how individual workers collectively view risk and risky behaviour ·         Decision-making frameworks “suggest that the concept of… Continue reading The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

What are the links between risk perception, safety climate, safety leadership and rule departure/adaptation? An upcoming summary explored these links in a sample of 390 power grid construction workers. Note: While this study talks of compliance (and associating rule following as ‘correct’ or ‘compliant’) and violations (I’ve never liked ‘violation’ because it’s so loaded and… Continue reading Risk perception, safety climate, leadership and rule departures

An absolute banger of a paper will be posted soon – co-authored by one of my favourites: the late, great Bob Wears. This paper talks about the corrupting, but understandable, factors that lead us to focus on constructing the past via hindsight and outcome bias in diagnostic failures (e.g. first stories over second stories). Out… Continue reading Replacing hindsight with insight and moving towards second stories of performance