All articles
Every article from the magazine, newest first.
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Checking Instead of Writing: Generative AI and the Check That Is First to Go Under Pressure.
Generative AI brings a safety promise into the office: the AI drafts, a human checks. That hands the human exactly the task Lisanne Bainbridge warned…
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Bainbridge: Ironies of Automation – and What Is Left for the Human.
In 1983 Lisanne Bainbridge wrote five pages for a control engineering journal. Her finding: we automate whatever can be automated, and the human gets the…
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What a Workaround Keeps Quiet
In American hospitals, nurses stuck barcodes to doorjambs so they didn’t have to scan at the bedside. The workaround is sensible, and it defeats the…
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Snook: Friendly Fire – and the Explanation Without a Culprit.
On 14 April 1994, two US F-15s shot down two US Black Hawks over northern Iraq. Twenty-six people died. Scott Snook spent two years looking…
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What Gets Rewarded Gets Done: Risk Culture Beyond the Framework.
Since 2008, risk culture has been treated as something that can be described and assessed by supervisors. Credit Suisse had the frameworks, the limits, the…
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98 Per Cent Ticked: What Became of Gawande’s Checklist.
In 2010 Ontario required every hospital to report publicly on its use of a surgical safety checklist. The teams reported near-complete use, and nothing changed…
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The Shadow Initiation Phase: When the Project Starts Before It Is Approved.
Every project method treats discontinuation as a proper decision. In practice it counts as failure, and somebody has to answer for it. People avoid that…
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Cooperating with an Investigation That May Never Happen
Both chambers of the Swiss Parliament have agreed to make exemption from prosecution for slight negligence conditional on cooperation with the official safety investigation. Over…
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Resilience Out of Necessity: What the Volunteer Fire Service Knows About the First Minutes.
High-reliability research developed its principles on aircraft carriers, in nuclear power stations and in air traffic control: full-time staff, stable crews, constant practice. The Swiss…
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Edmondson: The Fearless Organization – and the Silence That Kept the Peace
A captain at a European airline, asked in a survey about a moment when he should have stepped in, remembers that he did not. His…
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Nothing About Apollo 13 Was Improvised
Apollo 13 is remembered as the greatest improvisation in engineering history. Almost none of it was improvised. The rescue procedures came out of the debrief…
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Endsley: Situation Awareness, and What Accident Reports Made of It
Mica Endsley built a tool for system design and measurement. Accident investigation turned it into a finding: “loss of situation awareness”, cause, full stop. A…