Tag Archives: reductionism

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 ››

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 ››

What if we got it wrong?

file1851274688166People don’t come to work to be safe. They come to work to work. Or as a project manager once told me: -I probably spend about 50% of my day thinking about behaviours and safety. You probably close to 100% of yours. But what about the guys doing the job? We remind them of safety messages and what we think is important during pre-start meetings and toolbox talks. But then what? Then they’re off, focusing on other things. … Continue Reading ››

Tinker, Taylor…

The old English nursery rhyme "Tinker, Tailor, Soldier, Sailor" was adapted as title for John LeCarre's 1974 spy novel. Its main character, George Smiley, first fired, then reinstated, is the Beggar Man of the rhyme. At some point, he is involved in an operation called "Witchcraft", forcing a Soviet mole to reveal his identity. Smiley, naturally, becomes the hero. I have often written of a hero of our engineered world, Isaac Newton. He, after all, conceived of a world of laws and determinacy, a predictable world … Continue Reading ››

The evil of roots

file0002103473231 Transportation officials said Wednesday that the driver of the Green Line train that crashed into another trolley docked at the Boylston Street Station last week was “solely responsible” for the accident and that he would be fired. Accidents are surprising. That which previously was trustworthy, suddenly no longer is. And the mismatch between expectations and actual performance calls for an explanation. To learn from failures organisations and societies institute accident investigations. The task of such probes is traditionally … Continue Reading ››