The below images are really just an index from the book “Behind Human Error” – but nicely summarises some key concepts. The meaning of most items are obvious but I’ll explain some of the less obvious statements. #2 about erroneous assessments/actions being heterogenous indicates that performance is contextual, so grouping everything under a neat label… Continue reading System factors “behind human error”
Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units
This study explored organisational learning by way of specific learning activities within project teams. This occurred in the context of a complex service organisation (hospital). Providing background, it’s noted that: Results Learn-what and learn-how were positively correlated, as was psychological safety and learn-how activities. Learn-what and learn-how were also positively correlated with perceived implementation success.… Continue reading Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units
Psychosocial risks and hydrocarbon leaks – an exploration of their relationship in the Norwegian oil and gas industry
This explored the relationship between a psychosocial risk indicator (obtained via survey data) with hydrocarbon leaks on Norwegian oil & gas producing platforms and whether the indicator can be used as a proactive indicator for preventing such leaks. The study also factored in the some technical issues of offshore installations, including installation age, weight and… Continue reading Psychosocial risks and hydrocarbon leaks – an exploration of their relationship in the Norwegian oil and gas industry
Using Safety-II and resilient healthcare principles to learn from Never Events
A very interesting read. This used a secondary analysis (qualitative and quantitative) of 35 Root Cause Analysis (RCA) serious incident reports (‘Never Events’) from a NHS Foundation Trust. The goal was to see if and how Safety-II/resilient healthcare principles could contribute to the quality of investigation, e.g. understanding misalignments between demand & capacity, adaptive capacity,… Continue reading Using Safety-II and resilient healthcare principles to learn from Never Events
Psychological safety isn’t trust or team coherence
Amy Edmondson discusses some nuances about what group psychological safety is or isn’t. (I’ll post further on this in the near future). 1. It’s not coherence since coherence can make it more difficult to voice dissenting views (image 1). 2. It’s also not trust, but trust is important. Trust refers to interactions between two individuals… Continue reading Psychological safety isn’t trust or team coherence
Investigating a new classification to describe the differences between Work-As-Imagined and Work-As-Done
This brief conference study explored gaps between work-as-imagined (WAI) versus work-as-done in the field during real work tasks. Six workers at a petrochemical facility wore helmet mounted cameras and recorded undertaking filling operations. The video was then used to compare work practices against written process and coded using the WAI / WAD framework shown below:… Continue reading Investigating a new classification to describe the differences between Work-As-Imagined and Work-As-Done
Safety through engaged workers: The link between Safety-II and work engagement
This study mapped similarities between the concepts of work engagement and Safety-II (S-II) – and in particular, the antecedents for each. I’ve skipped large portions of this paper and particularly the research behind the engagement constructs (which I’ve mainly skipped to the S-II comparison discussion in each section), so recommend you check out the full… Continue reading Safety through engaged workers: The link between Safety-II and work engagement
Balancing Safety I and Safety II: Learning to manage performance variability at sea using simulator-based training
An interesting study exploring how simulator training of maritime deck officers can improve the management of Performance Variability (PV) & safety in critical operations at sea. Learning & PV was framed through the lens of Safety-I (SI) / Safety-II (S-II) & Resilience Engineering (RE). Too much to unpack so I’ll cover just a few points. … Continue reading Balancing Safety I and Safety II: Learning to manage performance variability at sea using simulator-based training
How complex systems fail (a classic from Richard Cook)
Another classic from Richard Cook, where he covers 18 principles on how complex systems fail. The paper is brief, freely accessible and an easy read. I’ve extracted the 18 principles with a small text description in the below images. Some random highlights for me are: Source: Cook, R. I. (1998). How complex systems fail. Cognitive… Continue reading How complex systems fail (a classic from Richard Cook)
Nine Steps to Move Forward from Error
A discussion paper from David Woods and Richard Cook where they explore some general research findings about how complex systems fail and how people contribute to safety. They argue that some common beliefs and fallacies on why high risk systems fail, and normally succeed, can hold back progress. There’s way too much to unpack from… Continue reading Nine Steps to Move Forward from Error
SafetyInsights.org 