SafetyInsights.org

Do debriefs/after-action reviews improve individual and team performance? This upcoming summary explored this question. 46 samples met inclusion into the meta-analysis. For background, they discuss how some sectors, like military, have used debriefs for decades. Debriefs are a form of “emergent learning”, where “individuals use an iterative process of reflection and planning to improve performance”.… Continue reading Debriefs/After-Action Reviews improve individual and team performance

Every year or two I re-read Vaughan’s work (book and key papers)…and each time all I can say is: oof. Some extracts: ·        “mistake, mishap, and disaster are socially organized and systematically produced by social structures” ·        “No extraordinary actions by individuals explain what happened” ·        “The cause of disaster was a mistake embedded in the banality of… Continue reading Challenger Launch Decision: socially constructed risk, the banality of organisational life, and disasters

This 3-year ethnographic study had the lead researcher embedded within the safety team on a large UK construction project as part of a larger project. In this study, the use and limitations of the safety observation reporting (SOR) system was discussed (the system for reporting safety issues or observations via computer or handwritten cards). N.B.… Continue reading Problems with safety observation reporting: A construction industry case study

I found this paper interesting – it evaluated the likelihood of a run of poor outcomes (mortality during surgery). Although it focuses on surgery, I think we could take lessons from the probabilities about runs of incidents in any other industry (e.g. construction incidents) – and the problem of knee-jerk reactions to statistical random variability… Continue reading Chance of runs of workplace accidents: How likely is it that a run of poor outcomes is unlikely?

I found this 1990 paper from Wagenaar, Hudson and Reason interesting (more from the historical perspective); but still pretty insightful. Note. Don’t read into the specific findings, nor the language used (e.g. “foolishness”) too much – it is >30 year old, after all. Some points covered: ·        Safety awareness initiatives tend to be among the most… Continue reading Cognitive failures and accidents

This meta-analysis explored the link between work injuries and mental health challenges. Providing background: ·       A large number of people “endure preventable work injuries and manageable mental health conditions”, and these issues are compounded by “widespread underreporting, driven by fears of repercussions, insufficient workplace accommodations, and complex reporting processes” ·       There’s limited consensus regarding the… Continue reading Work injuries and mental health challenges: A meta-analysis of the bidirectional relationship

This brief paper from Hollnagel & Macleod may interest you. Some key points: In sum, they answer three questions: Ref: Hollnagel, E., & Macleod, F. (2019). The imperfections of accident analysis. Loss Prevention Bulletin, 270(3), 2-6. Study link: https://www.icheme.org/media/12669/lpb270_pg02.pdf My site with more reviews: https://safety177496371.wordpress.com LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_this-brief-paper-from-hollnagel-macleod-activity-7200975055361613824-PTT1?utm_source=share&utm_medium=member_desktop

This study unpacked three workplace events, comparing each organisation’s investigation report to the researcher’s own evaluation from a cognitive trap (error trap) perspective. Note: I translated this from Portuguese via Google, so there could be mistakes. Providing context they note: ·         Criticism has emerged against “concepts that presuppose the existence of direct relationships between failures,… Continue reading Cognitive traps: the case of omissions in the genesis of work accidents

What proportion of chemical process incidents have design as a contributor? This study soon to be summarised explored these links. They analysed 284 major equipment-related accident cases from a database. What I liked about the definition of design in this study is that it went beyond just the literal plant/equipment view. Here, a “design error… Continue reading The role design error plays in chemical industry accidents

What is the relationship and directionality between work injuries and mental health challenges? That is, are work injuries more likely to precede mental health challenges or vice versa? This upcoming summary meta-analysis evaluated these links. Key findings: ·        There’s a consistent and modest link between work injuries and mental health challenges ·        The relationship is stronger when… Continue reading Are work injuries more likely to precede mental health challenges or vice versa?