Although it may be possible to accept that errors are neither as numerous nor as varied as they might first appear, the idea of a predictable error is a much harder one to swallow. If errors were indeed predictable, we would surely take steps to avoid them. Yet, they still occur. So, what is a…...
Safety Thought of the Week… predicting errors (James Reason) Read More »
I know I made these mistakes in my early years. In the early 1990’s “Behavior Based Safety” was all the rage, and it had me “hook, line, and sinker.” Sometimes, I wish I was still in contact with some operators/maintenance tech who got the raw end of our (mostly mine) investigations and causal analysis so…...
Safety Thought of the Week… are worker behaviors the problem? Read More »
In the past several decades, some organizational researchers and managers have used it to describe the norms and practices that organizations develop around their handling of people or as the espoused values and credo of an organization. This sometimes confuses the concept of culture with the concept of climate, and confuses culture as what is…...
Safety Thought of the Week… Culture: An Empirically Based Abstraction Read More »
The last few weeks I have been sharing passages from Dr. Todd Conklin’s books. And I could not agree more with 99% of what he teaches. This week is one of those 1%’ers… I believe that a GREAT Safety Management System (SMS) will in fact help organizations “learn” from accidents. Starting with a well established…...
Safety Thought of the Week… Not knowing is powerful Read More »
We must battle the need to believe that when a worker has some type of bad outcome, that adverse outcome happens because the worker becamemomentarily incompetent. Our thinking is driven by a bias toward bad things happening because someone did something bad. The bias that worker became stupid is really a strong force in how…...
Safety Thought of the Week… People do not just become stupid Read More »
I hate the phrase, “you can’t fix stupid.” It is offensive and mean; most importantly, that phrase is just wrong. Stop saying it. Stop using this phrase right now. “You can’t fix stupid” is serving you and your organization poorly. It colors your thinking, it makes you stop investigations too early, it sounds like something…...
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Safety Thought of the Week… Read More »
The accidents described in this chapter are not due to a fifth type of error. They are due to the failure of senior managers to realize that they could do more to prevent accidents. They are thus mainly due to lack of training, but some may be due to lack of ability and a few…...
Safety Thought of the Week… Trevor Kletz on “Organizational Failures” Read More »
A point has been reached in the development of technology where the greatest dangers stem not so much from the breakdown of a major component or from isolated operator errors, as from the insidious accumulation of delayed-action human failures occurring primarily within the organizational and managerial sectors. These residual problems do not belong exclusively to…...
Human factors, as we know it today, got its inspiration from these basic ideas about human error. It then showed something different: an alternative way of looking at human error. As a result, there are basically two ways of looking at human error today. We can see human error as a cause of failure, or…...
Safety Thought of the Week… Old View vs New View in Human Factors Read More »
Since we are in a snow apocalypse here in the Midwest, I thought I would lose my mind hearing all the “weather professionals” declaring that with wind chills below zero, the roads will freeze as the salt won’t work below 15F. And I thought these were “science-based” professionals. TIP: Wind chill is how the temperature…...
Safety Thought of the Week… Wind Chill Read More »
The environment, organization, economics, capabilities, technology, and regulatory context all change over time. This backdrop of continuous systemic change ensures that hazards and how they are managed are constantly changing. Progress on safety concerns anticipating how these kinds of changes will create new vulnerabilities and paths to failure even as they provide benefits on other…...
Safety Thought of the Week – Systems exist in a changing world Read More »
