A fantastic read from Gemma Read, Steven Shorrock, Guy Walker and Paul Salmon discussing the history of core theories and methods over the last 60 years around ‘human error’. Also discussed was the human error construct within ergonomics & human factors (EHF), some “key conceptual difficulties” that the human error construct faces in a systems… Continue reading State of Science – Evolving Perspectives on ‘Human Error’
Man-Made Disasters 20 years later: critical commentary
Another paper from the Barry Turner files from 1999, reflecting on the then 20 year period since Turner published his seminal work (this paper was written after his passing). Based on Turner’s analysis on the incubation of disasters: · Rigidities in perceptions and beliefs about what is and isn’t counted as a hazard. For instance, at… Continue reading Man-Made Disasters 20 years later: critical commentary
From punitive action to confidential reporting: A longitudinal study of organizational learning
This study explored the shift from a punitive to non-punitive reporting approach in a hospital over 2 years, while assessing the capacity and success of learning. Before the transition, an employee involved in an incident reported the event to his/her manager, who would then devise improvements (mostly in the form of a reminder to watch… Continue reading From punitive action to confidential reporting: A longitudinal study of organizational learning
‘Mistaking error’ – an earlier paper from David Woods & Richard Cook
A banger from Woods and Cook exploring the notions of ‘error’. Originally from 2004 and updated in 2012. I’ve skipped heaps – so check out the full paper. They argue that: · They refer to the progressive, adaptive perspective as the ‘New Look’ · Error is used inconsistently, since it can mean: o 1) a cause of failure,… Continue reading ‘Mistaking error’ – an earlier paper from David Woods & Richard Cook
Safe Work Method Statements a “shambolic mess … with incoherent risk assessments built off the back of equally incoherent risk matrices” – Greg Smith, Proving Safety
Well, Greg Smith doesn’t mince words about the application of Safe Work Method Statements (SWMS) – being typically a “shambolic mess … with incoherent risk assessments built off the back of equally incoherent risk matrices”. He also argues that they fail to properly address issues of criticality, where the management of high-risk work activities is… Continue reading Safe Work Method Statements a “shambolic mess … with incoherent risk assessments built off the back of equally incoherent risk matrices” – Greg Smith, Proving Safety
Blame Conformity: Leading Eyewitness Statements can Influence Attributions of Blame for an Accident
This study explored whether attributions of blame for an incident can be shifted between people due to leading eyewitness statement. The method had participants watch a video of an accident involving two men and read either a non-leading witness statement that blamed no one for the accident, or a leading eyewitness statement that blamed one… Continue reading Blame Conformity: Leading Eyewitness Statements can Influence Attributions of Blame for an Accident
Reconstructing human contributions to accidents: the new view on error and performance
Another earlier (2002) paper from Sid Dekker. It explores a shift in how the role of people in both (sometimes) failure, but usually success, is seen. Of course, there’s been a lot more since written on this; but still an interesting read. Personally, I’m less interested in the new vs old arguments; but the stuff… Continue reading Reconstructing human contributions to accidents: the new view on error and performance
Organisational learning and the shift to a non-punitive reporting approach
What is the relationship between learning and a shift to a non-punitive reporting approach? This 2007 study from Dekker and Laursen explored this question. Over a period of two years, a transition occurred in a hospital in how reporting was undertaken, and how managers responded. Before the transition, an employee involved in an incident reported… Continue reading Organisational learning and the shift to a non-punitive reporting approach
Organisations’ have no memory: Trevor Kletz on building collective mindfulness for major accident prevention
I’ve long been fascinated by this idea from Trevor Kletz (I love his work) about how organisations ‘have no memory’, and a way to maintain this collective human capability is to mark-up critical procedures, standards etc. with the reasons why those specifications exist. Examples would be critical investigation findings, or findings from experience, HAZOPs, and… Continue reading Organisations’ have no memory: Trevor Kletz on building collective mindfulness for major accident prevention
Breaking the rules: understanding non-compliance with policies and guidelines
This was a brief discussion paper about why people don’t always follow rules, but from the perspective of healthcare practitioners within the NHS. The findings themselves aren’t new or unique to healthcare but it’s good to see the perspective of the people that are required to follow all of the guidelines. I think many of… Continue reading Breaking the rules: understanding non-compliance with policies and guidelines
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