Tag Archives: Accident Investigation

Just culture: Who are we really afraid of?

When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’ (by whatever name), as well as official responses to these, at company and judicial level. The notion of just culture is driven partly by fear; fear of being judged and blamed, especially fear of being blamed unfairly. The fear is felt most strongly by operational staff, who are at the sharp end of organisations and have sometimes faced disciplinary … Continue Reading ››

Understanding and Adding to the Investigation Toolbox

For the last century, the evolution of accident investigation can be tied to research and the scientific advancements in how we view our work systems[1]. Three major lenses of scientific research emerge as we begin to examine key influences on accident investigation processes: Classic mid-century faith in engineering was termed, Scientific Management, which was followed by Systems Thinking and, ultimately, an emerging understanding of Complex Adaptive Systems.   Continue Reading ››

Why focus on conditions?

We have long struggled with trying to capture the facts associated with an accident in order to prevent the next one. This has been largely effective when applied to machines. In mechanical systems things are measurable, observable and more objective. The information we get from people is always subjective. There are always issues of memory, shame, fear and politics that influence the ever-changing stories we tell. If you think about it, you have probably altered a story to … Continue Reading ››

Thinking differently about safety investigations

file000704919536Systems exist and function within diverse societal environments reflecting numerous societal constructs that have evolved over time in all societies. Societal constructs about justice, personal rights, behavioral norms, education, economics, governance, and others influence safety program and investigation perceptions, constructs and practices. Those societal constructs and their influences need to be incorporated by academics and practitioners into a new and broader “societal” socio-technical vision horizon for both safety programs and safety investigations if existing concerns, issues and … Continue Reading ››