Tag Archives: complexity

Why do things go right?

Photo by Josue Isai Ramos Figueroa on Unsplash
In his 2014 Safety I and Safety II: The past and future of safety management, Erik Hollnagel makes the argument that we should not (just) try to stop things from going wrong. Instead, we need to understand why most things go right, and then ensure that as much as possible indeed goes right. It seems so obvious. Yet it is light years away from how most organizations … Continue Reading ››

Rush to judgment

In our rush to judgment we rarely intend to do harm. Often, we react to incomplete or even scant information, fit it into our own mental model of how things should be and then jump to conclusions that could inflict harm. Last week, CBS Morning News showed a film clip of a man snagging a baseball from a kid who was sitting directly in front of him. The less than 10 second clip resulted in the vilification of … Continue Reading ››

7 Implications of Complexity for Safety

One of my favourite articles is The Complexity of Failure written by Sidney Dekker, Paul Cilliers, and Jan-Hendrik Hofmeyr.  In this posting I'd like to shed more light on the contributions of Paul Cillliers. Professor Cilliers was a pioneering thinker on complexity working across both the humanities and the sciences. In 1998 he published Complexity … 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 ››

Should we do a safety audit or do safety differently?

This is a continuation of Daniel Hummerdal's 2016 April 06 "Safety Audits Differently" posting. Universe made of stories Imagine you work in a company with a good safety record. By "good",  you are in the upper quartile as per the benchmarking stats in your industry.  Things were rolling along nicely until this past year. There was a steep increase in failures which has led to concerns over the safety culture. Historically there have 2 safety-related events but last year there … Continue Reading ››

Emergence of Safety-III

Reductionism
During engineering school in the late 1960s I was taught to ignore friction as a force and use first order approximate linear models. When measuring distance, ignore the curvature of earth and treat as a straight line. Break things down into its parts, analyze each component, fix it, and then put it all back together. In the 1990s another paradigm coined Systems Thinking came about we … Continue Reading ››

Danger was the safest thing in the world if you went about it right

Stunt pilotThis seemingly paradoxical statement was penned by Annie Dillard. She isn’t a safety professional nor a line manager steeped in safety experiences. Annie is a writer who in her book The Writing Life became fascinated by a stunt pilot, Dave Rahm. "The air show announcer hushed. He had been squawking all day, and now he quit. The crowd stilled. Even the children watched dumbstruck as the slow, black biplane buzzed its way around the air. Rahm made … Continue Reading ››

Risky empathy

if you want to understand riskI saw this poster in an airport some time ago. It is an advert for an insurance company and shows a person in a helicopter with a note, "One thing, if you want to understand risk, you need to get out from behind your desk".  How connected are safety specialists with operational staff and the operational environment, where the day-to-day safety is created, to understand the operational world? How much of our … Continue Reading ››

Tinker, Taylor, Culture, Failure

file9001254174340 -When are managers and supervisors going to sign their commitment? The above question was raised when 30 or so workers were asked to read and sign their commitment to the organisational Safety Culture values. It happened during one of their fortnightly safety meetings. My presence was merely as an observer. -Well, we started with this level, and then we'll do supervisors' and managers' responsibilities as the next step, the safety supervisor replied. Individuals are different. By definition. Any one organisation … Continue Reading ››

Sex and poetry

file000500940833None of us said anything for a while. At the other end of the table was a safety manager for a construction company. I had just described some ideas on how to do safety differently. -No. What we need is to find the right way to do it. Once we have that, we’ll put it into practice across every project. I had tried to explain why safety can never be achieved with a one size fits all solution. And I had described why … Continue Reading ››