All articles
Every article from the magazine, newest first.
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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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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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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…
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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.