When General Stanley McChrystal took over the U.S. Joint Special Operations Command (JSOC) in Iraq during the mid-2000s, he inherited an organisation struggling to overcome the Al Qaeda insurgency plaguing the country. After a few weeks in the job, he realised his new team had been viewing their enemy through the wrong lens, and therefore had been using the wrong strategies to defeat them. Ultimately, this insight led him to … Continue Reading ››
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 ››
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 ››
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.
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. 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.
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This is a continuation of Daniel Hummerdal's 2016 April 06 "Safety Audits Differently" posting.
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 ››
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 ››
This 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 ››
I 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 ››
-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 ››