SafetyInsights.org

Tom McDaniel‘s post yesterday about safety narratives reminded me a little of safety archetypes. Safety archetypes are models, patterns or universally recognisable ideas that can be found in organisations. They can be applied to normal or successful work, or for failures. Not surprisingly, the latter has been studied a lot. This study explored system archetypes… Continue reading Modeling patterns of breakdown (or archetypes) of human and organizational processes in accidents using system dynamics

What is the role of checklists and time-outs in preventing adverse events? What additional measures are needed to reduce these events? This brief study, including Sid Dekker and Nancy Leveson, explored these questions in the context of healthcare. I think the general questions and thinking is applicable elsewhere from a systems perspective. Not a summary… Continue reading When a checklist is not enough: How to improve them andwhat else is needed

This was a fascinating read, exploring objectivist and constructivist explanations and reflections around the public inquiry into the Waterfall train accident; and namely how a myopic objectivist focus on rational decision-making and technology may lead to blame and a weak understanding of sociotechnical & social systems. The findings are framed within John Downer’s concept of… Continue reading Blaming Deadmen: Causes, Culprits, and Chaos in Accounting for Technological Accidents

Are accidents more likely in a low, moderate or high hazard environment? In a moderately hazardous environment, according to this upcoming study. Over four protocols they explored the protective behaviours people adopt in response to workplace hazards (what they termed ‘safety behaviour’), and how these behaviours scale in response to low, medium and high hazardousness.… Continue reading Accidents more likely in a moderately hazardous workplace, compared to high or low hazardous, according to this study

How accurate and comprehensive are incident reporting systems compared to the actual frequency and severity of events that occur? According to this study, not very. This interesting study compared medication errors of medical personnel (while observed by an observer) to the frequency and types of medication errors and events reported in the official system. It’s… Continue reading Inaccuracy and misdirected decisions-making in incident reporting systems

Concepts like safety, quality, transparency, accountability are said to be “Nice words, great values”, but their management “is not always well-received by workers, as safety and quality do not have the same connotations as safety management and quality management”. Moreover, their management generates work that “interfere with the core work, or “real work”, as it… Continue reading Untangling Safety Management: From Reasonable Regulation to Bullshit Tasks

I’m currently trying to refresh some of our thinking and approach in prospective learning and investigations; drawing heavily on Leveson’s work (among others). The attached comes from Leveson’s CAST handbook. Leveson evaluates the Shell Moerdijk Explosion in order to explain her CAST approach (based on STAMP & STPA). Although all the different hierarchical levels of… Continue reading Better ways to learn from investigations via systems thinking: Leveson and CAST/STAMP/STPA

This studied, via interview, differences between how procedure administrators (representing work as imagined, WAI) perceive the design and use of procedures versus the realities of procedure users (work as done, WAD) across several large, international chemical sites. Providing background: ·       While procedure use/departures are mentioned across many major accidents, procedure users in some data reported… Continue reading The realities of procedure deviance: A qualitative examination of divergent work-as-done and work-as-imagined perspectives

This was a fascinating read, exploring objectivist and constructivist explanations and reflections around the public inquiry into the Waterfall train accident; and namely how a myopic objectivist focus on rational decision-making and technology may lead to blame and a weak understanding of sociotechnical & social systems. I can’t do it justice. Some of the key… Continue reading The folly and blame of objectivist and rationalistic investigations – the Waterfall train accident

This explored the effectiveness of incident reporting systems (IRSs) for improving patient safety and on effectiveness on learning. The relationship between incident reports & actions were evaluated on changes in practice and whether the changes involved settings, processes or outcomes. Further, single-loop learning (correction of operational issues without significantly changing the overall structure or beliefs)… Continue reading How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review