Leveson & Cutcher-Gershenfeld discuss systems safety in the context of the Columbia Accident Investigation Board (CAIB) investigation. NB. These types of analyses are, of course, replete with hindsight and outcome logics, and sometimes judgmental attributions (failure, inadequate). But that doesn’t inherently mean we can’t learn anything. Extracts: · “The CAIB report describes system safety engineering at… Continue reading What System Safety Engineering Can Learn from the Columbia Accident (Nancy Leveson)
Tag: systems engineering
Failure modes analysis of organizational artefacts that protect systems
Really interesting 2004 paper discussing how to study the failures associated with organisational artefacts. Artefacts are “rules, procedures, instructions, authority structures and so on that are designed, like physical devices, but have organizational rather than physical functions”. It’s argued that studying failures of artefacts, like in FMEA, isn’t the same as physical failure modes, and… Continue reading Failure modes analysis of organizational artefacts that protect systems
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
Resilience terminology and a visualisation of resilience/robustness in practice
This may interest people. It covers concepts of resilient performance within seaports. It’s a bit random (seaports), but otherwise gives a handy overview of resilience terms and applications. The first two images are just basic definitions. Extracts: · Image 3 represents resilience elements during disruptions – from pre-disruption, to the disruption, then post-disruption. · During pre-disruption, the… Continue reading Resilience terminology and a visualisation of resilience/robustness in practice
The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
This was a really brief discussion paper from Dekker and Leveson, covering systems thinking in medicine. Three parts – see comments. Nothing new for most, but they cover: · “The ‘systems approach’ to patient safety has recently led to questions about its ethics and practical utility” · E.g. A recent paper from a retired neurosurgeon questioned systems… Continue reading The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
SafetyInsights.org 