A few extracts from chapter 11 in Foundations of Safety Science by Bergström and Dekker I found interesting. Here they discuss research in healthcare how: · Nursing was found to have some 600 rules specifying a ward nurses daily work · But, nurses could recite just 2-3 of the 600 rules that “supposedly specify their job” · Despite… Continue reading The fallacy of relying on rules for robust risk management in complex high-risk environments
Tag: false safety
Safe AF #9: How certified systems & auditing mask psychosocial factors
We design, implement and ISO-certify our safety systems with best intentions. We hope these systems help us to identify and address workplace hazards. However, is it possible that certified management systems can instead mask particular complex sociotechnical issues, simplifying psychosocial matters into neat, auditable matters, devoid of their depth and nuance? Can auditing transform functional… Continue reading Safe AF #9: How certified systems & auditing mask psychosocial factors
Safe AF #7: Limits of investigations and blindness to control effectiveness
Are our investigations blinded to the functioning and effectiveness of risk controls? Are our current approaches, and mental models about how safety events occur, defined less by what they unpack and more by what they leave in the dark? This study unpacks these questions, and evaluates how accident investigators consider, or not, the functioning of… Continue reading Safe AF #7: Limits of investigations and blindness to control effectiveness
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
Ineffective audits and systems and false safety: Maritime NZ legal case
Third post from the Maritime NZ case where the CEO was charged under a failure to exercise due diligence for a work fatality (Ports of Auckland Limited (POAL). Some extracts on audits (and systems in post 2 in comments): · “Any effective system should also incorporate regular review and audit processes” · “the prosecution submits that prior… Continue reading Ineffective audits and systems and false safety: Maritime NZ legal case
The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
“There was a very real sense in which all three parties were simply going through the motions together of producing ‘paper safety’” This is a nearly 600 page accident inquiry for the 2006 military aircraft accident – just a few extracts I found interesting regarding broader safety management. It’s a fantastic read and a masterclass… Continue reading The Nimrod accident inquiry: An exploration of paper safety, clutter, false safety and more
Audits, excessive compliance focus and risk blindness
Still genuinely surprised that our last paper on audit failures has generated, relatively speaking, so much interest: now the second-most accessed paper in the Process Safety Progress journal. [* It shows as number 1 but that’s a glitch in the matrix. There’s a study on ‘red squirrels tests’ that has HEAPS more views.] No doubt… Continue reading Audits, excessive compliance focus and risk blindness
Fantasy planning: The gap between systems of safety and safety of systems
Not sure if I ever properly shared this – but this was my first conference paper released back in 2018. It’s a HIGHLY condensed version of a much larger paper I wrote, and hope to publish one day. It covers a range of topics around symbolic safety, false assurance, ‘fantasy planning’, and catastrophic accidents which… Continue reading Fantasy planning: The gap between systems of safety and safety of systems
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