A brief article from Hollnagel on the ‘arbitrariness’ of accident analyses. Relying on a lot of direct quotes. First it’s argued that one of the many myths within safety is that accident analysis / investigation “is a rational search for (root) causes”. By this logic, the purpose of an investigation is to found out what… Continue reading The Arbitrariness of Accident Analysis
Tag: hollnagel
Safe AF #10: Are safety myths –like most accidents due to human error –holding us back?
Are our safety myths–like most accidents being the result of human error–holding back genuine improvement within safety? Can myths like these actually hamper learning, and increase operational risk? Today’s article is from Besnard, D., & Hollnagel, E. (2014). I want to believe: some myths about the management of industrial safety. Cognition, Technology & Work, 16, 13-23. Make… Continue reading Safe AF #10: Are safety myths –like most accidents due to human error –holding us back?
The Folly of Safety-III
Hollnagel’s response to some of the recent (and somewhat bizarre) articles on ‘Safety-III’. Spoiler: It’s not charitable. I’m relying on a lot of direct quotes. Providing context, Hollnagel argues: · Introduction of Safety-I and Safety-II (SI / SII) to characterise two opposite means of safety was “met with surprisingly large interest” and “also with some… Continue reading The Folly of Safety-III
Root-Causal Factors: Uncovering the Hows & Whys of Incidents
This 2016 article from Fred Manuele explores some facets of causality in investigations. It’s based mainly on two key sources: Hollnagel’s 2004 ‘Barriers and accident prevention’ and Dekker’s 2006 ‘Field Guide to Understanding Human Error’. Won’t be much new for most but has some nice arguments from authors like Hollnagel, Dekker and Leveson. First he… Continue reading Root-Causal Factors: Uncovering the Hows & Whys of Incidents
Human Performance Tools: Engaging Workers as the Best Defense Against Errors & Error Precursors
This article covered a more progressive view on human performance, with suggestions on some tools. Too much to cover, so just a few points. They start by saying to consider three truisms: “To err is human. Workers are fallible. Errors are inevitable (as well as predictable)”. These are fundamentals to understanding the human performance approach… Continue reading Human Performance Tools: Engaging Workers as the Best Defense Against Errors & Error Precursors
Procedure excellence: Changing paradigms to enable human reliability
This paper from Elliot Wolf-Stokes and Rob Fisher may interest peeps – around orientating towards operational excellence. Covers a lot of ground – systemic drivers to procedural departures, error drivers in written guidance, mental models, enablers of human reliability and more. I’ve skipped HEAPS, so just a few extracts (link to full paper in comments):… Continue reading Procedure excellence: Changing paradigms to enable human reliability
Foundation of Safety Science: Resilience Engineering and complex systems pt2
Post 2 from ch.11 of the Foundations of Safety Science, exploring Resilience Engineering (RE) and the adaptive perspectives. Some extracts: · RE sees failures not necessarily as breakdowns or malfunctioning of normal functions, but “the converse of the adaptations necessary to cope with the real world complexity” · Performance of individuals and organisations across all level “must… Continue reading Foundation of Safety Science: Resilience Engineering and complex systems pt2
When Things Go Right: Safety II in an Academic Emergency Department
This study explored variability and ED clinician proactive adaptations in order to enhance safety in the face of demands and pressures. Data was based on a cross-sectional survey. Background: · Patient safety, according to one agency, is defined as “the prevention of errors, injury, or other preventable harm and reduction of unnecessary harm” · They… Continue reading When Things Go Right: Safety II in an Academic Emergency Department
Human Factors and New Views of safety applied to management systems: A systematic literature review
This conference paper from Leonidas Brasileiro, Julio Cesar de Faria Alvim Wasserman and Gilson Brito Alves Lima may interest you. It explored how different concepts under HF and New View have been applied to management systems via literature review (2000 – 2023). Note: I’ve skipped a lot, so check out the paper. Some extracts: · “New… Continue reading Human Factors and New Views of safety applied to management systems: A systematic literature review
The harms of promoting ‘Zero Harm’
This brief editorial discussed some challenges to zero harm approaches (‘absolute safety’) in healthcare. I particularly liked how the author argued that not only is zero harm not attainable, in an absolute sense, but “is unknowable”. Some points: · The authors encourage shifting away from ‘absolute safety’ “towards doing a better job of actively managing risk,… Continue reading The harms of promoting ‘Zero Harm’
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