“What is wrong with posters and exhortations? They are directed at the wrong people”. So Deming wisely argues. For Deming: · Such exhortations are problematic since they to “arise from management’s supposition that the production workers could, by putting their backs into the job, accomplish zero defects, improve quality, improve productivity, and all else that is… Continue reading Deming: “Eliminate numerical quotas for the work force” and exhortations for accountability, since they are “directed at the wrong people”
Tag: systems-thinking
Preventing serious injuries & fatalities: time for a sociotechnical model for an operational risk management system
Here’s a 2008 article from Fred Manuele which was included in my SIF compendium (link to compendium & article below). Fred explores a sociotechnical approach to preventing SIFs. The fatality rate in the US from 1971 to 2005 decreased from 17 to 4, but remained stable from 06 to 2011 at ~3.5; hence SIF prevention… Continue reading Preventing serious injuries & fatalities: time for a sociotechnical model for an operational risk management system
Leverage points to intervene in a system – Donella Meadows
In the lead up to next week’s compendium on systems thinking, here’s a banger from Donella Meadows. She explores system leverage points. Not a summary, but some extracts: · Leverage points are “places within a complex system .. where a small shift in one thing can produce big changes in everything” · The “state of the system”… Continue reading Leverage points to intervene in a system – Donella Meadows
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
Learning from normal work: How to Proactively Reduce Risk When Nothing Goes Wrong
An interesting article from Marcin Nazaruk, exploring learning from everyday work. Skipping a bit, so check out the full article. First he says that while it’s important to learn from failure “it is too late”. For one, diminishing incident rates “can no longer accurately reflect safety performance … and simply focusing on behaviours and unsafe… Continue reading Learning from normal work: How to Proactively Reduce Risk When Nothing Goes Wrong
Leveraging Ergonomics and Human Factors (E/ HF) for community impact: what have we learned about how to make a difference
This was a banger – exploring the application of community ergonomics with a strong systems lens. If you’re interested in HF/E, systems thinking, social dynamics, power gradients and more then this will interest you. Can’t do it justice, so a few random extracts. Extracts: Finally they talk about ways to improve this practice – via… Continue reading Leveraging Ergonomics and Human Factors (E/ HF) for community impact: what have we learned about how to make a difference
Foundations of Safety Science: Resilience Engineering and 3 analytical traps for resilience practitioners
Post 3 from ch.11 of the Foundations of Safety Science, exploring Resilience Engineering (RE) and the adaptive perspectives. This part focuses on 3 analytical traps for resilience practitioners/scholars to be cognisant of (you may recognise these from Johan Bergstrom’s youtube vid – link in comments). Extracts: · The first trap is the reductionist trap · Whereas “the… Continue reading Foundations of Safety Science: Resilience Engineering and 3 analytical traps for resilience practitioners
Escaping Failures of Foresight
An interesting discussion paper from David Woods, in response to a paper from Andrew Hopkins discussing process safety indicators (see my article from a few weeks back). ** I haven’t done a good job of this – so suggest you read the original paper. You might want a strong coffee. Woods takes a bit of… Continue reading Escaping Failures of Foresight
A Systems Thinking Approach to Leading Indicators in the Petrochemical Industry
I’m putting together the next Research Compendium, covering indicator definitions, frameworks and examples. Showing my own bias is a focus on Nancy Leveson’s work. This post has some extracts from her article ‘A Systems Thinking Approach to Leading Indicators in the Petrochemical Industry’. This is based on what Leveson calls “assumption-based indicators”. That is, developing… Continue reading A Systems Thinking Approach to Leading Indicators in the Petrochemical Industry
From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
This 2018 paper explored the effects of a re-designed Just Culture (JC) process in an international energy company. It’s a solid read and worth your time – I’ve had to skip heaps. Providing background: · This organisation started using the James Reason JC framework in 201, but collective experience in the organisation “indicated that the… Continue reading From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
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