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 seminal book The Limits of Safety, Scott D. Sagan contrasted two schools of thought to assess the safety performance of the United States nuclear weapon system during the era of the Cuban Missile Crisis: High reliability theory and complexity theory. One of the basic tenets regarding high reliability organizations is that they are able and willing to learn from events. Sagan, however, found that oftentimes, the U.S. military failed to learn from the incidents they … Continue Reading ››
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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In this case study I would like to show a practical application of the Functional Resonance Analysis Method (FRAM) to investigate the process of trains departing the station. The reason for analyzing this process, is that Signal Passed At Danger (SPAD) incidents have a specific category that deals with situations where this incident happens just after leaving the station. So in that case, the first signal seen from the station platform is passed while it shows … Continue Reading ››
A client approached us about a recent incident in a process involving three organizations. They asked for an independent investigation into the incident. During the initial meeting it became clear that there was some relevant history to the process in which the incident happened.
The comedian Bill Hicks died just over 20 years ago. He was not 'just a comedian'. He was a social critic and stand-up philosopher. There were few others like him at the time, and few others have come near him since. Freedom of thought and speech were at the core of what Hicks did. He believed that popular culture was a passive, silenced and dumbed-down culture - one that is easier to control. He encouraged people to think, to question everything: "Folks, … Continue Reading ››
The other night I attended a meeting of safety practitioners. This is your typical monthly meeting that local chapters of safety societies have – where we get together to network, eat typically mediocre food (admittedly, I’m a picky eater), and hear a presentation on some topic of interest to the safety industry. This particular presentation focused on an insider from the state regulatory body exposing the flaws in the current regulatory structure. The advertisement for the presentation … Continue Reading ››
In September, a EUROCONTROL Network Manager White Paper was released, entitled Systems Thinking for Safety: Ten Principles. The White Paper was a collaboration of EUROCONTROL, DFS, nine other air navigation service providers and three pilot and controller associations. The purpose is to encourage a systems thinking approach among all system stakeholders to help make sense of – and improve – system performance. The Executive Summary of the … Continue Reading ››
I recently gave a talk about Safety Differently to a group of, mostly, safety professionals. As usual, I offended some people with my spontaneous jokes (this is easier to do in some places than in others, believe me), and made those who have vested interests in the old paradigm squirm or look shell-shocked (“but, but, my posters saying that ‘safety is our number ONE priority’ actually work…!”). Also, as usual, I divided … Continue Reading ››