Another extract from an upcoming summary from Mark Cannon & Amy Edmondson about ‘failing intelligently’. They talk about the various technical, social and structural barriers for organisations to effectively learn from small & large failures. In this section they zero in on the individual and manager-levels: · “Even outside the presence of others, people have an… Continue reading “A natural consequence of punishing failures is that employees learn not to identify them, let alone analyze them, or to experiment if the outcome might be uncertain” Amy Edmondson on ‘failing intelligently’
Resilient Procedures: Oxymoron or Innovation?
An interesting chapter from the late Bob Wears around ‘resilient procedures’. I’ve skipped heaps. They specifically explore: · what baggage tends to accompany procedures · what is bad about procedures · what is good about them · how procedures might be designed to support or even enhance resilience, instead of degrading it. Procedures are said… Continue reading Resilient Procedures: Oxymoron or Innovation?
Tight coupling, interactive complexity and an operator zigging instead of zagging known only in hindsight: Charles Perrow
Some wisdom from Perrow’s awesome Normal accidents. This book is full of nuggets, so just some random extracts: · “But if … the operator is confronted by unexpected and usually mysterious interactions among failures, saying that he or she should have zigged instead of zagged is possible only after the fact” · “Before the accident no one… Continue reading Tight coupling, interactive complexity and an operator zigging instead of zagging known only in hindsight: Charles Perrow
Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
This study unpacked what investigators look at and how they construct causes in high-speed workboats. It employed a Safety-II / HOP / HF perspective. Tl;dr: human factors are poorly evaluated and largely seen as individual-level factors. Some extracts: · “Although the analysis focused on negative observations, it also identified HFs that supported the activity” · “Many pivotal… Continue reading Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
The mixed blessing of risk defences and redundancy: James Reason
A few random extracts from James Reason’s timelessly awesome Managing the Risks of Organizational accidents. (Note: This isn’t an endorsement of the somewhat linearity of defences-in-depth, since we have evidence that emergent behaviour can playout in reality and with equifinality etc) There’s hundreds of things I could extract (and maybe will in time), but here’s… Continue reading The mixed blessing of risk defences and redundancy: James Reason
Above the line, below the line – Richard Cook on complex systems failure and recovery
A cool paper from Richard Cook about internet/software failures and complex systems. I’m not a software person – but still found it pretty interesting. ** Parts 2 & 3 in comments ** Just a few extracts: Ref: Cook, R. I. (2020). Above the line, below the line. Communications of the ACM, 63(3), 43-46. Shout me a coffee… Continue reading Above the line, below the line – Richard Cook on complex systems failure and recovery
Efficacy and Understanding of the Safety Hierarchy of Controls
This PhD thesis from Stephen Young was interesting. They studied evidence supporting the hierarchy of control (HOC), constraints on its efficacy, and more. Way too much to cover. Some extracts: · There isn’t a lot of evidence supporting the efficacy of the HOC · One reason is: “An unequivocal demonstration of efficacy [of the HOC] is problematic,… Continue reading Efficacy and Understanding of the Safety Hierarchy of Controls
“I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
“Every intelligent system makes errors”, so said Gerd Gigerenzer. Here’s a couple of page extracts from a 2005 paper. Not sure if I’ll summarise it or not (it’s really interesting, but tough to capture in a summary…) The paper: · Challenges the rationalistic and normative ideal as cognition as purely a logical and rational one, ignoring… Continue reading “I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
This study explored whether outcome bias might explain why healthcare investigations focus on individual culpability over addressing latent conditions in the system. 212 participants were allocated to one of three scenarios followed by the findings of an investigation (see scenario overviews below). For background: · Prior work has identified that the “overwhelming majority of recommendations… Continue reading Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies
This is long overdue – but I wanted to cover some of the work from these giants who have played a significant part in modern safety thinking. Focus is on articles I’ve written about or used extracts from, or could find a full-text link for, and higher-cited articles. It’s not systematic – and unfortunately a… Continue reading An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies
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