Understanding safety holistically –
without oversimplification.
Weekly articles from research and consulting practice: safety culture, human factors, high-reliability organisations, learning from incidents, and risk management. Every Monday.
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The Salute That Sank the Costa Concordia – How a Routine Drifts Onto the Rocks
Read article: The Salute That Sank the Costa Concordia – How a Routine Drifts Onto the RocksOn 13 January 2012 the Costa Concordia sailed too close to an island, 32 people died, and one captain took the entire blame. But the…
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Weick & Sutcliffe: Managing the Unexpected, and Why Reliability Is an Activity
Weick and Sutcliffe’s five HRO principles are often read as a maturity checklist. The book argues against exactly that reading: reliability is not a state…
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The Assumption Behind the Incident: Single-Loop, Double-Loop, and the Gap in Inquiry
After an incident, the typical review changes the procedure, not the assumption behind it. Single-Loop corrects the action; Double-Loop asks about the assumption that helped…
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Restorative Just Culture: The Other Question After an Incident
Retributive Just Culture asks who broke the rule. Restorative Just Culture asks who is hurt and what those affected need in order to keep working.…