System Safety: Seven Foes of Explanation

In this short series, I will highlight seven foes and seven friends of system safety, both for explanation and intervention. Each is a concept, meme, or device used in thinking, language, and intervention (reinforced by more fundamental foes that act as barriers to thinking).  They are not the only foes or friends, of course, but they are significant ones that either crop up regularly in discussions and writings about safety, or else – in the case of friends – should do.

The Real Second Victims

In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example that has played on my mind over recent years is the term ‘second victim’.

Human Factors at The Oscars

It has variously been described as “an incredible and almost unbelievable gaffe” (Radio Times), “the greatest mistake in Academy Awards history” (Telegraph), “an extraordinary blunder…an unprecedented error” (ITV News), “the most spectacular blunder in the history of the starry ceremony” and “the most awkward, embarrassing Oscar moment of all time: an extraordinary failure” (Guardian). It was, of course, the Grand Finale of the Oscars 2017.

Never/zero thinking

There has been much talk in recent years about ‘never events’ and ‘zero harm’, similar to talk in the safety community about ‘zero accidents’. It sounds obvious: no one would want an accident. And we all wish that serious harm would not result from accidents. But as expressed and implemented top-down, never/zero is problematic for many reasons. In this post, I shall outline just a few, as I see them.