All articles
Every article from the magazine, newest first.
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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…
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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.…
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Resilience Is Not What Most People Mean by It
What organisations call “resilience” is usually robustness, and in complex systems often its opposite. An essay on a consequential confusion.
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Conklin: Pre-Accident Investigations, When Incidents Are the Second-Best Option
Todd Conklin inverts safety work: the most valuable investigation is the one you run while nothing has happened yet. A book note on the mindset…
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What Happens Between Audits
Audits check states on a fixed date. Safety is a process. About the second layer of safety work that needs to stand between the audits,…
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Field Guide to Understanding Human Error – a note on Sidney Dekker
A book note on Sidney Dekker’s classic: why “human error” is never the end of an investigation, but its beginning. With the tools Local Rationality,…
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People are not the weak link
US Airways 1549, Hudson 2009: what saved Sully that day wasn’t the procedure. A case for questioning the standard “human error” diagnosis, and what it…
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What it means to tailor a system
Three principles for the craft that gives this magazine its name: measure instead of assuming, respect the fabric, build adjustment in. With a tailor’s workshop…
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Three Assumptions We Need to Leave Behind
From a Three Mile Island indicator that showed a command instead of a state to three assumptions that still shape how we read safety. A…
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How our mental picture can endanger us
Why “false alarm” is one of the most dangerous terms in everyday firefighting work. How the mental picture we bring into an operation shapes our…