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
Tag: safety-ii
Safe AF ep #5: Is what we find in investigations, what we fix?
Conventional logic suggests that we fix the gaps that we find in investigations. But is this the case? Is the investigation process more a game of sociopolitical whack-a-mole, finding and fixing the things that are easily solved or understandable, or tolerable to the organisation? Ref: Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you… Continue reading Safe AF ep #5: Is what we find in investigations, what we fix?
Designing for resilient performance & worker participation: design principles
This review explored how to design for worker participation, drawing on the design of resilient systems. Not much to say – the extracts cover core resilient design principles. Some extracts to contextualise the images: · Participation refers to “the worker’s influence in decision-making related to safety, involving information sharing between people” · “Design for resilient performance Design… Continue reading Designing for resilient performance & worker participation: design principles
Management of safety rules and procedures
Really interesting report from Hale, Borys & Else about the nuances of rules, and contrasting model 1 / model 2. [* Check out this week’s compendium dedicated to Hale & Hopkins, link below] A few extracts: · A classic Dutch railways study showed that 3% of workers used rules often and 50% almost never, 47% found… Continue reading Management of safety rules and procedures
Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review
This systematic review covers strategies and tools used in healthcare patient safety for learning from normal work and Safety-II. 22 articles met inclusion. For background: · In healthcare “underreporting is highly prevalent, and is linked to, among other things, shaming and blaming mentality, insufficient visible measures and inadequate communication about errors” · “most reporting systems… Continue reading Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review
Open-access healthcare debriefing videos need to incorporate more Safety-II learnings
Are Safety-II concepts used in debriefing? This explored the language and framings used in open access debriefing videos, to ascertain whether the questioning probes deeper into S-I (focus on failure/error) or S-II (focus on normal work, variability, success) questioning. Note: Only 7 videos met inclusion for transcription/evaluation. They note that learning from success isn’t “uncommon… Continue reading Open-access healthcare debriefing videos need to incorporate more Safety-II learnings
The human factor: Pursuing success and averting drift into failure – YT video, Sidney Dekker
A 2018 presentation from Sid Dekker on success and drift into failure. One of many such, and no particular reason why this one over any other. Sid starts with an example he heard, supporting the bad apple thesis: “just get rid of the nurses who make mistakes and all will be a lot safer” “Now… Continue reading The human factor: Pursuing success and averting drift into failure – YT video, Sidney Dekker
Compendium of Nancy Leveson: STAMP, STPA, CAST and Systems Thinking
Although I don’t often mention or post about Leveson’s work, she’s probably been the most influential thinker on my approach after Barry Turner. So here is a mini-compendium covering some of Leveson’s work. Feel free to shout a coffee if you’d like to support the growth of my site: https://direct.mit.edu/books/oa-monograph/2908/Engineering-a-Safer-WorldSystems-Thinking-Applied https://doi.org/10.1177/0170840608101478 https://doi.org/10.1145/7474.7528 http://therm.ward.bay.wiki.org/assets/pages/documents-archived/safety-3.pdf http://sunnyday.mit.edu/papers/Rasmussen-Legacy.pdf https://www.tandfonline.com/doi/pdf/10.1080/00140139.2015.1015623… Continue reading Compendium of Nancy Leveson: STAMP, STPA, CAST and Systems Thinking
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
Designing work systems for resilient performance: insights from resilience engineering
This explored Design for Resilient Performance (DfRP) via their framework. Not a summary – just a few extracts, but maybe I’ll summarise it in the future. Some extracts: · “Resilient performance (RP) is a socio-technical system’s ability to adjust its functioning prior to, during, or following changes and disturbances, thereby sustaining operations under both expected and… Continue reading Designing work systems for resilient performance: insights from resilience engineering
SafetyInsights.org 