A really interesting conference paper from Andreas Bye, discussing whether shifting Human Reliability Analysis (HRA) terminology from human error to human success would help alleviate some of the blame-connotations. Also discussed is the human role in automated systems. It was meant to be a mini-post with a few dot-points and a couple of images, but… Continue reading Human Success: Old wine in new bottles, or a shift of mindset for HRA in an automated world?
Tag: resilience engineering
Understanding Accidents – From Root Causes to Performance Variability
This 2002 discussion paper from Erik Hollnagel unpacks some assumptions of different accident models. Note: In this work, accident model isn’t the specific tool or method (e.g. ICAM), but a “frame of reference as the accident model, i.e., a stereotypical way of thinking about how an accident occurs”. i.e. the mental models and justifications on… Continue reading Understanding Accidents – From Root Causes to Performance Variability
The difference between ‘making do’ and resilience in complex systems
This paper explores the difference between ‘making do’ and resilience. Not a summary, but a few extracts: · Making do has been defined, from a waste perspective as “a situation where a task is started without all its standard inputs, or the execution of a task is continued although the availability of at least one standard… Continue reading The difference between ‘making do’ and resilience in complex systems
Compendium: Learning and improvement without incidents
Here’s a mini-compendium of…well, probably a lot of stuff with only a tenuous link to ‘learning’. I tried to focus on learning that doesn’t require incidents, but you’ll find those here, too. There’s >100 articles, mostly full-text. I think I went overboard. Unfortunately, it’s barely sorted. It includes: Shout me a coffee Learning Strengths &… Continue reading Compendium: Learning and improvement without incidents
Analyzing Procedure Performance using Abstraction Hierarchy: Implications of Designing Procedures for High-risk Process Operations
This paper explored the use of procedures and operator performance from the perspective of work domain analysis/abstraction hierarchy. I’ve skipped heaps – the ‘doing’ part of the abstraction hierarchy, but their descriptions of the problem and the discussion had some gold. For context: · Procedural issues have been linked in a number of major accidents… Continue reading Analyzing Procedure Performance using Abstraction Hierarchy: Implications of Designing Procedures for High-risk Process Operations
‘They didn’t do anything wrong! What will I talk about?’ Applying the principles of cognitive task analysis to debriefing positive performance
An interesting paper exploring the use of Safety-II inspired debriefs, learning from successful performance. They used cognitive task analysis techniques. Not a summary, but it’s open access and really brief – so check it out 👍 Extracts: · “simulation cases are often deliberately designed to push learners to their zone of proximal development .. where perfect… Continue reading ‘They didn’t do anything wrong! What will I talk about?’ Applying the principles of cognitive task analysis to debriefing positive performance
Resilient Procedures: Oxymoron or Innovation?
An interesting chapter from the late Bob Wears around ‘resilient procedures’. I’ve skipped heaps. They specifically explore: · what baggage tends to accompany procedures · what is bad about procedures · what is good about them · how procedures might be designed to support or even enhance resilience, instead of degrading it. Procedures are said… Continue reading Resilient Procedures: Oxymoron or Innovation?
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
Hollnagel on “Human error”: error as cause, process or outcome
Not much to say – some extracts from a 2007 chapter from Erik Hollnagel, unpacking whether we really need “human error”? I knocked the summary up last night and will probably post in the next couple of weeks. Oh man, I need to give up on chapters…what a slog. He argues: · Human error “is not… Continue reading Hollnagel on “Human error”: error as cause, process or outcome
Contextualising new safety paradigms: A study in a large Australian construction company
This study explored the presence, implementation, appetite and feasibility of 12 principles representing “new safety paradigms”. It involved focus groups with 53 participants and a cross-sectional survey of 514 employees. I’ve skipped HEAPS (actually, the entire results section – so check out the full paper). Background: · “The review by Karanikas et al. (2022) revealed… Continue reading Contextualising new safety paradigms: A study in a large Australian construction company
SafetyInsights.org 