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Tag Archives: human error
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’. Continue reading
Posted in Safety
Tagged ethics, human error, organisations, second victims, third victims
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Just Culture in La La Land
It was always going to happen. The wrong Best Picture winner was read out live on air at The Oscars. Someone had to take the blame. Attention first turned to Warren Beatty and Faye Dunaway. They, after all, ‘touched it last’. But … Continue reading
Posted in Culture, Human Factors/Ergonomics, Humanistic Psychology, Safety, systems thinking
Tagged human error, just culture, safety, safety culture
4 Comments
Human Factors at The Oscars
“An extraordinary blunder” 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 … Continue reading
Posted in Human Factors/Ergonomics, Safety, systems thinking
Tagged decision making, design, human error, human factors, Oscars, safeguards, safety-II, uncertainty, work-as-done
10 Comments
Human Factors at The Fringe: My Eyes Went Dark
Written and directed by Matthew Wilkinson. A thrilling modern tragedy about a Russian architect driven to revenge after losing his family in a plane crash. Cal MacAninch and Thusitha Jayasundera give electrifying performances in this searing new play about the … Continue reading
Posted in Human Factors/Ergonomics, Safety, systems thinking
Tagged accidents, art, blame, human error, human factors, just culture, management, safety, systems thinking, theatre
7 Comments
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. Continue reading
Posted in Human Factors/Ergonomics, Safety, systems thinking
Tagged accidents, blame, human error, human factors, just culture, management, never events, safety, safety-I, safety-II, systems thinking, targets, zero harm
8 Comments
‘Human error’ in the headlines: Press reporting on Virgin Galactic
Again, a familiar smoke pattern has emerged from the ashes of a high-profile accident. The National Transportation Safety Board held a hearing in Washington D.C. on 28 July 2015 on the Virgin Galactic crash over California on October 31, 2014. … Continue reading
Posted in Human Factors/Ergonomics, Safety, systems thinking
Tagged accidents, blame, ergonomics, human error, human factors, Language, safety-I, safety-II, social media, systems thinking
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Reducing ‘the human factor’
If you work in an industry such as transportation or healthcare – where human involvement is critical – you have probably heard people talk about ‘the human factor’. This elusive term is rarely defined, but people often refer to reducing it, or perhaps mitigating it. … Continue reading
