Are audits implicated in major accidents? My second audit paper reviewed thousands of major accident reports, exploring how investigators framed the role of audits prior to the accident. Surprisingly, very few investigations mentioned the role of audits – positively, negatively or neutrally (just 44 reports out of thousands). Check out the full paper below. We… Continue reading Safety audits and major disasters: are they connected?
Tag: accident
Safe AF #6: Audit Masquerade – How audits provide comfort rather than treatment for serious risks
Are audits effective checks and verifications of our risk control systems? Are they diving deep into the functionality and effectiveness of systems and practices, and evaluating actual daily, hazardous work? Or, are they mostly rustling paperwork at the expense of operational hazards? Ref: Hutchinson, B., Dekker, S., & Rae, A. (2024). Audit masquerade: How audits… Continue reading Safe AF #6: Audit Masquerade – How audits provide comfort rather than treatment for serious risks
Safe AF ep #4: Relationship between fatal and non-fatal accidents based on 23k accidents
Is there a connection between fatal and non-fatal accidents, or is it a fallacy to focus on the minor potential events with the hope of managing the major events? Today’s study explores these relationships based on 23k reported serious accidents in the Netherlands. Ref: Bellamy, L. J. (2015). Exploring the relationship between major hazard, fatal… Continue reading Safe AF ep #4: Relationship between fatal and non-fatal accidents based on 23k accidents
Compendium: SIFs, Major Hazards, Fatal & Traumatic hazards, risks
This is an expansion to my prior compendium on Critical Controls, Barriers and Energy thinking. Suggest you read that in conjunction to this, link here: Barriers, Critical Controls, Verifications, Energy Models If you’re after indicators check this mini-compendium out: Safety & Risk Performance indicators (lead, lag, drive, process safety + more) This compendium focuses on articles… Continue reading Compendium: SIFs, Major Hazards, Fatal & Traumatic hazards, risks
Visualizing what’s missing: Using deep learning and Bow-Tie diagrams to identify and visualize missing leading indicators in industrial construction
This study, among a few other things, compared 633 incidents against >9 inspection reports with similar contexts to understand the overlap. Data was from a Canadian construction project over 3 years. E.g. They used multi-methods, including natural language processing, text mining, bow ties and more to evaluate if field inspections are looking at the same… Continue reading Visualizing what’s missing: Using deep learning and Bow-Tie diagrams to identify and visualize missing leading indicators in industrial construction
Failing to learn and learning to fail (intelligently): How great organizations put failure to work to innovate and improve
An interesting paper from Mark Cannon & Amy Edmondson about failing intelligently. Opening the paper they argue that while the idea of organisations learning from their failures is obvious – “yet organizations that systematically learn from failure are rare”. They’ve also found that few organisations effectively experiment to learn, which requires by necessity generating failures… Continue reading Failing to learn and learning to fail (intelligently): How great organizations put failure to work to innovate and improve
“there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Extracts from Dekker’s work about the ontological and empirical shakiness of ‘root causes’. I’ve taken material from two versions of The Field Guide to Understanding Human Error (Investigations). In Dekker’s view: · “There is no ‘root’ cause” (or ‘root causes’) · Given the multiple angles and interactions in complex systems, you “can really construct “causes” from everywhere”… Continue reading “there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Co-exposures to physical and psychosocial work factors increase the occurrence of workplace injuries among French care workers
Psychosocial and physical workplace exposures found to be co-related in workplace injury (WI), according to this study. It’s one of heaps of studies highlighting the interactions between psychosocial factors and physical and psychological injury. E.g. Physical exposures were on their own were not great predictors of self-declared injury, and it was the interactions that best… Continue reading Co-exposures to physical and psychosocial work factors increase the occurrence of workplace injuries among French care workers
Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
This systematic review evaluated evidence for what support staff want vs what they receive, and whether the support is effective. 99 studies were included. Some extracts: · PSI (patient safety incident) lead to emotional shame, guilt, anger, shock, depression, fear, flashbacks, helplessness, fatigue, withdrawal and more · The three most desired support types staff want before and… Continue reading Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
Resilience terminology and a visualisation of resilience/robustness in practice
This may interest people. It covers concepts of resilient performance within seaports. It’s a bit random (seaports), but otherwise gives a handy overview of resilience terms and applications. The first two images are just basic definitions. Extracts: · Image 3 represents resilience elements during disruptions – from pre-disruption, to the disruption, then post-disruption. · During pre-disruption, the… Continue reading Resilience terminology and a visualisation of resilience/robustness in practice
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