Understanding work-as-done seen as critical for PCBUs and CEOs/Officers, according to this prosecution of a CEO who failed to exercise due diligence relating to a work-related fatality (Ports of Auckland Limited (POAL). Extracts: · “[234] “Work as done” is the reality of work as it is actually carried out by the workers on the shop floor.… Continue reading Importance of understanding work-as-done: Fascinating extracts from CEO due diligence prosecution
Rail suicide: A systematic review using systems thinking
This systematic review evaluated rail suicide research against the systems thinking techniques AcciMap & PreventiMap. Some extracts: · “In Australia, 67 suicides by train occurred across 2019–20, representing 80 % of all fatalities occurring on the railways” · “Rail suicide is distinct in that in addition to the person who dies by suicide [and the familiy/friends affected],… Continue reading Rail suicide: A systematic review using systems thinking
“A good leader and a conscientious officer may have the best intentions in the world but may still breach that duty”: Fascinating legal case of CEO due diligence prosecution
Fascinating read of a CEO charged for not exercising due diligence, resulting tragically from a work-related death (Ports of Auckland Limited (POAL). Posted over multiple days, as it also covers work as done, critical risks, audits, indicators, inconsistent nightshift practices and more. Starting with due diligence: · “A good leader and a conscientious officer may have… Continue reading “A good leader and a conscientious officer may have the best intentions in the world but may still breach that duty”: Fascinating legal case of CEO due diligence prosecution
“Managing the risks of major accidents” – Andrew Hopkins, YouTube presentation
A 2024 YT video from Andrew Hopkins about managing the risks of major accidents. This comes in the lead up to next week’s compendium of research dedicated to Andrew Hale & Andrew Hopkins. Some extracts: · He refers to the Safety Paradox where managers “honestly believed that safety was their top priority that they never sacrificed… Continue reading “Managing the risks of major accidents” – Andrew Hopkins, YouTube presentation
The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
“There was a very real sense in which all three parties were simply going through the motions together of producing ‘paper safety’” This is a nearly 600 page accident inquiry for the 2006 military aircraft accident – just a few extracts I found interesting regarding broader safety management. It’s a fantastic read and a masterclass… Continue reading The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models
Does the Swiss Cheese metaphor hold its own against systemic accident models? Yes, according to this study. Seems topical to share this paper, comparing the ATSB variant of a Swiss Cheese accident model vs AcciMap and CAST (i.e. STAMP). They found: · “each model applied the systems thinking approach” · “However, the ATSB model and AcciMap graphically… Continue reading Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models
Compendium: Leadership / Safety Leadership / Leaders Behaving Badly / Followership
Here’s a mini-compendium of research surrounding leadership, safety leadership and followership. NOT systematic – there’s way too much to cover in this space. Focus is on the links between leadership attributes / interventions on indices of performance. The other focus is on studies I’ve either summarised or could locate a full-text link for. ** For… Continue reading Compendium: Leadership / Safety Leadership / Leaders Behaving Badly / Followership
The harm of counterfactual normative judgements in investigations – book ‘Human and Organizational Potential’
Another extract from Pupulidy and Vesel’s book ‘Human and Organizational Potential’. This part looks at counterfactual thinking in investigations: · “Counterfactuals are statements that are contrary to what actually happened” · Counterfactuals “expresses what could have, would have, or should have happened… but didn’t” · Problematically, counterfactuals as normative judgements during investigations describe a reality that did not… Continue reading The harm of counterfactual normative judgements in investigations – book ‘Human and Organizational Potential’
What are we to make of safe behaviour programs?
A 2006 article from Andrew Hopkins, discussing some merits and limitations of behavioural approaches to safety. A lot of research has been done on behavioural safety approaches since 2006, but still a pretty reasonable article. Note: This is broader than BBS, but that’s a well-known iteration. Tl;dr – Hopkins argues: · “Safe behaviour programs run… Continue reading What are we to make of safe behaviour programs?
Safety Management Systems, safety clutter and illegitimate tasks (“BS work”)
Safety Management Systems and the problem of clutter and illegitimate core tasks (“bullshit tasks”). I’ve posted this paper before (see links), but here’s another extract. I don’t have much to say, as it doesn’t need explaining. The paper is worth a read, though. Author: Størkersen, K. V. (2024). Auditism: Symptoms, Safety Consequences, Causes, and Cure.… Continue reading Safety Management Systems, safety clutter and illegitimate tasks (“BS work”)
SafetyInsights.org 