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Tag Archives: just culture
System Safety: Seven Foes of Intervention
In this short series, I 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.
In this post, I outline seven foes of intervention. Continue reading
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, healthcare, human error, just culture, justice, organisations, second victims, third victims
2 Comments
Four Kinds of ‘Human Factors’: 1. The Human Factor
This is the first of a short blog post series, on four kinds of ‘Human Factors’: ‘The Human Factor. Continue reading
Posted in Human Factors/Ergonomics
Tagged blame, ergonomics, human factors, Humanistic psychology, just culture, systems thinking, the human factor, work
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
Just culture: Who are we really afraid of?
When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’ (by whatever name), as well as official responses to these, at company and judicial level. The notion of just culture is driven … Continue reading
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
9 Comments
Occupational Overuse Syndrome – Human Error Variant (OOS-HEV)
Occupational Overuse Syndrome – Human Error Variant (OOS-HEV) is a condition involving the overuse of the notion of ‘human error’ to explain unwanted events in complex systems. The condition develops as the result of a number of factors such as the desire … Continue reading
Safety-II and Just Culture: Where Now?
When things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems … Continue reading
‘Human error’: The handicap of human factors, safety and justice
“Oh my God. I told those guys at safety that it was dangerous and one day we would lose concentration and pay for it. I already told those guys at safety that it was very dangerous! We are human and … Continue reading
