Tag Archives: systems thinking

The Varieties of Human Work

The analysis of work cannot be limited to work as prescribed in procedures etc (le travail prescrit), nor to the observation of work actually done (le travail réalisé). Similarly, it cannot be limited to work as we imagine it, nor work as people talk about it. Only by considering all four of these varieties of human work can we hope to understand what’s going on. Continue reading

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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

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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

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‘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

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Systems Thinking for Safety: From A&E to ATC

This article summarises a EUROCONTROL Network Manager White Paper called 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 … Continue reading

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Is ‘human error’ the handicap of human factors? A discussion among human factors specialists.

Following most major accidents, one phrase is almost guaranteed to headline in the popular press: ‘human error’. The concept is also popular in the ergonomics and human factors (EHF) discipline and profession; it is probably among the most profitable in … Continue reading

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Paramedics under pressure: A case study for systems thinking

Learning systems thinking is best done by doing. Case studies are useful ways to understand some basic principles, and I find that it can be useful to use case studies from other sectors, especially with a mixed audience. Cases that … Continue reading

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