Accidents more likely in a moderately hazardous workplace, compared to high or low hazardous, according to this study

Are accidents more likely in a low, moderate or high hazard environment? In a moderately hazardous environment, according to this upcoming study. Over four protocols they explored the protective behaviours people adopt in response to workplace hazards (what they termed ‘safety behaviour’), and how these behaviours scale in response to low, medium and high hazardousness.…

Inaccuracy and misdirected decisions-making in incident reporting systems

How accurate and comprehensive are incident reporting systems compared to the actual frequency and severity of events that occur? According to this study, not very. This interesting study compared medication errors of medical personnel (while observed by an observer) to the frequency and types of medication errors and events reported in the official system. It’s…

Untangling Safety Management: From Reasonable Regulation to Bullshit Tasks

Concepts like safety, quality, transparency, accountability are said to be “Nice words, great values”, but their management “is not always well-received by workers, as safety and quality do not have the same connotations as safety management and quality management”. Moreover, their management generates work that “interfere with the core work, or “real work”, as it…

Better ways to learn from investigations via systems thinking: Leveson and CAST/STAMP/STPA

I’m currently trying to refresh some of our thinking and approach in prospective learning and investigations; drawing heavily on Leveson’s work (among others). The attached comes from Leveson’s CAST handbook. Leveson evaluates the Shell Moerdijk Explosion in order to explain her CAST approach (based on STAMP & STPA). Although all the different hierarchical levels of…

The realities of procedure deviance: A qualitative examination of divergent work-as-done and work-as-imagined perspectives

This studied, via interview, differences between how procedure administrators (representing work as imagined, WAI) perceive the design and use of procedures versus the realities of procedure users (work as done, WAD) across several large, international chemical sites. Providing background: ·       While procedure use/departures are mentioned across many major accidents, procedure users in some data reported…

The folly and blame of objectivist and rationalistic investigations – the Waterfall train accident

This was a fascinating read, exploring objectivist and constructivist explanations and reflections around the public inquiry into the Waterfall train accident; and namely how a myopic objectivist focus on rational decision-making and technology may lead to blame and a weak understanding of sociotechnical & social systems. I can’t do it justice. Some of the key…

How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

This explored the effectiveness of incident reporting systems (IRSs) for improving patient safety and on effectiveness on learning. The relationship between incident reports & actions were evaluated on changes in practice and whether the changes involved settings, processes or outcomes. Further, single-loop learning (correction of operational issues without significantly changing the overall structure or beliefs)…

Reasonable tasks, clutter and bullshit tasks in the pursuit of safety management

What is the relationship between reasonable tasks, clutter, and bullshit tasks in safety management? An upcoming summary explored these links, tracing the connection from regulation to internal requirements. Some points: It’s open access, so you can freely read the chapter and book. Authors: Størkersen, K. V., & Fyhn, H. (2024). In Compliance and Initiative in the…

Towards a conceptual framework for resilience engineering

I found this paper pretty interesting. It’s from 2008 and provides a good primer on resilience engineering, defining types of systemic disruptions that our systems may encounter, and then some principles and heuristics that may be useful. It’s from the infancy of Resilience Engineering as a distinct area of focus, but still holds up to…

“Do audits improve the safety of work” – Discussion about my two audit papers on the Safety of Work podcast

See below for a link to the Safety of Work podcast, where I discuss the implications of my two studies on safety auditing.