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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What a Good Audit Can Do – Beyond Audit Theatre
Read article: 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…