SafetyInsights.org

This study explored how worker perceptions of positive and negative procedure attributes were linked to procedure compliance, and the influence of management approaches to procedures. Data came from 176 maintainers in the mining industry. For background: ·        They briefly cover the model 1 and model 2 thinking of procedures (which notably are more complimentary than confrontational).… Continue reading Are you sure you want me to follow this? A study of procedure management, user perceptions and compliance behaviour

A month ago Abhijith Balakrishnan posted an apt quote (link below) about the tensions workers face between being thorough versus efficient in the moment (which Hollnagel coined as ETTO); often known only in hindsight which was more appropriate. This reminded me of a few references in Perrow’s seminal Normal Accidents book, where he nicely referred… Continue reading Zigging when you should have zagged: the clarity of hindsight

This 1998 paper explored how safety climate and communication—organisational factors—influence the interpretation of accident contributing factors/causes. Accident vignettes were used in two different settings. Vignettes were manipulated to have either internal cues (clues/factors pointing to a worker as the main contributor/cause of an accident) and external cues (factors outside of the worker’s control). Providing background,… Continue reading The role of safety climate and communication in accident interpretation: Implications for learning from negative events

What-you-look-for-is-what-you-find. In other words, if you go into something expecting to find error, non-compliance, management or design issues, you will likely find them (see Friday’s post, linked in comments). As Scott Snook put it regarding the accidental shootdown of two friendly US Blackhawk helicopters in 1994, “the more expected an event, the more easily it… Continue reading Safety investigations and political sensemaking

By interviewing 22 accident investigators, they studied constraints that lead investigations away from the “ideal” assumption that “what-you-find-is-what-you-fix” (WYFIWYF). That is, how does the same organisational context contributing to accidents constrain the investigation methods and understanding? Results Investigators believed that their investigations followed the ideal WYFIWYF; however data suggested that the analysis & design of… Continue reading What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions

Another study exploring rail safety events using HFACS. This evaluated 78 reports across 5 different types of incident. All the usual caveats and limitations exist with evaluating and categorising incident reports. It does provide interesting insights on how rail investigators think about performance and contributing factors, though. The HFACS model is shown below: Results Some… Continue reading Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents

This studied sleep duration, sleep quality and a range of other sleep factors related to rotating shift workers in the US oil industry (n = 351). All data was via survey (including sleep logs), so note that limitation. Providing background, it’s noted: ·        Since the 90s, most refineries in the US have been staffed via two… Continue reading Shift Work and Sleep Disturbance in the Oil Industry

This study explores several research questions around how well companies in oil & gas (pipeline companies specifically) find and fix issues when they occur, and what factors may contribute to workplaces that consistently fail to find and fix issues (risk accommodation). Incident data from 34 companies over 12 months was included. Results: Of the 2,552… Continue reading Failing to Fix What is Found: Risk Accommodation in the Oil and Gas Industry

A few weeks ago I posted 3 of 5 failure patterns based on David Wood’s chapter from “Organization at the limit: Lessons from the Columbia disaster” (link to the first post and David’s article in comments). Here are 4 and 5. #4 Failure to revise assessments as new evidence accumulates This relates to the challenging… Continue reading Five common patterns of disaster – post 2

This evaluated the link between work schedules and workplace incidents and near miss reporting. A large dataset consisting of a crew schedule calendar from 2016-2018 of a Fortune 500 company (which had 350 operators at the time of the study) were evaluated. This included day and night shifts. Providing background they note: Results Key findings… Continue reading Do employees’ work schedules put them at-risk? The role of shift scheduling and holidays in predicting near miss and incident likelihood