Safety Thought of the Week

Post-accident remedies for “human error” are usually predicated on obstructing activities that can “cause” accidents. These end-of-the-chain measures do little to reduce the likelihood of further accidents. In fact, the likelihood of an identical accident is already extraordinarily low because the pattern of latent failures changes constantly. Instead of increasing safety, post-accident remedies usually increase…...

Growing up in the Process Safety world with OHSA’s PSM and EPA’s RMP standards, I thought everyone had a “Safety Management System.” In school, we learned about OSH Management Systems and all they could do for a business. However, when I started consulting in 2005, I realized that SMSs were elusive in industrial facilities. Even…...

As an accident investigator this has to be one of my favorite books. Of course, I am a massive fan of Dekker’s books and videos. He has a newer book on this topic that is also a MUST-READ for safety professionals and accident investigators. After nearly 16 years as a safety professional in the chemical…...

James Reason’s Human Failure Model: Active and Latent [Organizational] Failures As safety professionals, we need to understand that we ALL make errors, mistakes, and violations. When we are asked to facilitate a causal analysis, it is incumbent upon us to keep the team aware of this fact and educate them on the differences between Active…...

Complex systems contain changing mixtures of failures latent within them The complexity of these systems makes it impossible for them to run without multiple flaws being present. Because these are individually insufficient to cause failure they are regarded as minor factors during operations. Eradication of all latent failures is limited primarily by economic cost but…...

If you really want to get a feel for the culture around safety, STOP with the surveys and get with today’s technology Three of my five bosses throughout my career all had this same practice, which is far more telling than a “survey.” And with today’s technology, such as cameras and drones, there is a…...

“… an attitude of frustration or an internal state of distress can certainly influence driving behaviors, and vice versa. Indeed, internal (unobserved) personal states of mind continually influence observable behaviors, while changes in observable behaviors continually affect changes in person states or attitudes. Thus, it is possible to “think a person into safe behaviors” (through…...

Safety should be an unwritten rule, a social norm, that workers follow regardless of the situation. It should become a value that is never questioned—never compromised. It is human nature to shift priorities, or behavioral hierarchies, according to situational demands or contingencies. But values remain constant. The early morning anecdote illustrates that the activity of…...

Catastrophe requires multiple failures – single-point failures are not enough The array of defenses works. System operations are generally successful. Overt catastrophic failure occurs when small, apparently innocuous failures join to create opportunity for a systemic accident. Each of these small failures is necessary to cause catastrophe but only the combination is sufficient to permit…...

Why do “lagging indicators” remain such a popular means of gauging/measuring the success of the safety effort?  We should measure the results and that these lagging indicators can/do play a role in measuring our success in all functions within a business. However, as I would like to point out to C-Suite executives, the company does…...

A bloody episode in a long war introduces the idea that defenses designed to protect against one kind of hazard can render their users prey to other kinds of danger, usually not foreseen by those who created them or even appreciated by those who use them. In short, defenses can be dangerous. This is no…...

It is suggested that LATENT ORGANIZATIONAL failures are analogous to the “resident pathogens” within the human body, which combine with external factors (stress, toxic agencies, etc.) to bring about disease. Like cancers and cardiovascular disorders, accidents in complex, defended systems do NOT arise from single causes. They occur through the unforeseen (and often unforeseeable) concatenation…...