All articles
Every article from the magazine, newest first.
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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…
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Planning the Return or Building Adaptation? Why BCM Is No Proof of Resilience
When the pandemic came, few organisations had a pandemic plan. Where one existed, it described the wrong pandemic. Organisations with plans and organisations without came…
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What a Good Audit Can Do – Beyond Audit Theatre
“Audit theatre” is a convenient diagnosis. It mistakes the tool for its use. There are organisations that train before an audit not to say anything…
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Hollnagel: FRAM, and Why Accident Analysis Must Begin with Normal Work
Last week’s Swiss cheese essay ended with a promise: a method that begins where the slices end. Erik Hollnagel’s FRAM is that promise. A book…
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The Swiss Cheese Myth – What the Most Famous Image in Safety Science Conceals
No image has shaped safety science like James Reason’s Swiss cheese: slices, holes, an arrow punching through. After the Überlingen collision it seemed to be…
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The Salute That Sank the Costa Concordia – How a Routine Drifts Onto the Rocks
On 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…