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 safety
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
“Those found responsible have been sacked”: some observations on the usefulness of error
Another interesting paper co-authored by the late Richard Cook. This paper discusses the usefulness of error. It’s a larger post with a lot of quotes – I just can’t do a better or more succinct job of restating what they’ve already written. Providing background, they argue that while some see “error” as a dead-end, others… Continue reading “Those found responsible have been sacked”: some observations on the usefulness of error
SafetyInsights.org 