Think of the safety journey as one of the vast improvements. When we first started managing safety, we did it by making and enforcing rules about safety and we got better, much better. Then we started to level out, we plateaued in our performance and needed to do something different. Safety got better and then […]
Despite their huge diversity, each organizational accident has at least three common features: hazards, failed defences, and losses (damage to people, assets and the environment). Of these, the most promising for effective prevention are the failed defences. Defences, barriers, safeguards, and controls exist at many levels of the system and take a large variety of
I used this humorous video to open my casual analysis training. Every parent has been there, but our kids’ curiosity is great. It’s how they LEARN. Sure, they may not understand all they are hearing (the same goes for adults in accident investigations), but that curiosity is what we need when leading a causal analysis
Violations arise from motivational factors and fall into four types:routine (or corner-cutting) violations, thrill-seeking or optimizing violations, necessary violations and exceptional violations. Unsafe acts are of two distinct types: errors and violations. Errors arise from informational problems and fall into three categories: Everyone makes errors.
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
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
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
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
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
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
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
