SafetyInsights.org

This paper explored the evidence around the types of biases and noise present in incident investigations and then some proposed solutions. It’s said that the investigation literature doesn’t comprehensively address this topic. I’ve had to skip large parts of this, so check out the full paper. Bias is “the systematic deviation from evidence-based, objective judgment”… Continue reading Cognitive bias in workplace investigation: Problems, perspectives and proposed solutions

This study explored the effects on team performance where not all members of a team necessarily agreed on the level of psychological safety within the team (e.g. dispersed perceptions of team psychological safety [PS]). >1k members of 160 management teams were studied. Providing background, it’s said: Results Key findings included: Discussion Summarising the findings, the… Continue reading Safe Among the Unsafe: Psychological Safety Climate Strength Matters for Team Performance

Lisanne Bainbridge’s 1982 paper on the ironies of automation is a classic; I’ve posted extracts before (as have many others – seriously, the paper is worth your time). James Reason (source below, pg. 43) provided a nice summary of the paper’s key points in the attached image. But, briefly, efforts to automate systems and remove… Continue reading Risks of automation and removing people

This study investigated biases in the context of risk assessment workshop facilitation and then mapped these against Rasmussen’s socio-technical systems model. Interviews with 23 facilitators and technical experts was undertaken. Three research questions drove the investigation: (p5) Providing background, it’s said: Some common types of biases are presented below. Results Six biases emerged from the… Continue reading The risk of risk assessments: Investigating dangerous workshop biases through a socio-technical systems model

This explored the negative effects of HRO chronic collective mindfulness practices within US law enforcement. They argue that HRO research “has nearly always presented HRO theory positively, causing a skewed perspective that favors implementation of these principles without adequate understanding of the costs to HRO members of chronic mindfulness” (p1). The two research questions were:1.… Continue reading The human cost of chronic mindfulness in U.S. law enforcement: toward a more nuanced understanding of HRO theory

This explored how safety management factors (SMF), contextual factors (e.g. project & org. complexity) & combinations of factors are linked to Safety Performance (SP). 12 construction companies were compared using SP data, interviews & audit results. Small sample, so caution is advised. Included factors and definitions below. Results Expectedly, a higher average score on 12… Continue reading A comparative analysis of safety management and safety performance in twelve construction projects

Another graphic from James Reason. In his vulnerable system syndrome paper (link below) he talks about types of “pathologies” present in many organisation; which predispose them to adverse events. Three interacting and self-perpetuating elements are involved: blaming front-line individuals, denying the existence of systemic issues and a blinkered pursuit productive and financial indicators. Three core… Continue reading The blame cycle

A really interesting study which explored the relationship between cultural factors and organisational failures. 58 studies were included in the review. Way too much to cover in this paper – I recommend you grab the full paper if it interests you. Also, for those critical of “safety culture”, this paper more explores how research has… Continue reading Causal and Corrective Organisational Culture – A Systematic Review of Case Studies of Institutional Failure

Another earlier paper (2004) paper from James Reason, talking about the progression of active and latent conditions related to a fatal medication event. From this he discusses enhancing “error wisdom” to buttress organisational safety approaches. Note – I think some of the terminology and ideas are a bit dated. However, if you apply a modern… Continue reading Beyond the organisational accident: the need for ‘‘error wisdom’’ on the frontline

The follow up paper on cognitive debiasing. This paper covers a scheme of cognitive change relating to debiasing, the constraints to change, and then a range of techniques directed at cognitive and affective debiasing. [** Note that there’s more systematic and recent reviews on debiasing techniques. I’ll cover some of these in the near future.]… Continue reading Cognitive debiasing 2: impediments to and strategies for change