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
Tag: safety differently
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
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
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