The sinking of the HMNZS Manawanui demonstrates how traditional safety ‘frames’ and ‘primes’ investigations. Here we have reported by the Chief of Navy for New Zealand stating: ‘Chief of Navy Rear Admiral Garin Golding said it was “too early to speculate” whether mechanical failure or human … [Read more...] about Framing and Priming Investigations, The Manawanui Tragedy
Investigation
Investigating Accidents – Who Needs To Learn
Much is written and shared about accident investigations and how to learn from accidents. Yes, a lot of learning comes from understanding the behaviour of people and the context that shapes their behaviour. But a lot of learning can also come from how we create, share and understand the accident … [Read more...] about Investigating Accidents – Who Needs To Learn
Critical Issues in Investigations not Addressed in Latest AIHS BoK Chapter
In all of my time undertaking investigations I have found there is no more important skill than pastoral care. Knowing how to recognise persons who are traumatised and how to respond is critical for any first responders or investigators. Unfortunately, people in safety are not educated in the … [Read more...] about Critical Issues in Investigations not Addressed in Latest AIHS BoK Chapter
The Bogus Bow-Tie Myth
Continuing our series on Safety Myths – see them all here There’s no doubt about it, Safety loves the linear in-out binary box. This is not just manifest in the swindle swiss-cheese but in many other safety myth models eg. The Bow-Tie that perpetuate the mythologies of certainty, control, order, … [Read more...] about The Bogus Bow-Tie Myth
Investigations and The Simplicity Attraction
Investigations and The Simplicity Attraction In the face of so much noise, competing values, diversity and confusion stands the myth of Occam’s Razor, a wish that when faced with multiple factors, humans will always opt for the shortest simplest route. The 14th Century philosopher/theologian … [Read more...] about Investigations and The Simplicity Attraction
What Theory of Learning is Embedded in Your Investigation Methodology?
What Theory of Learning is Embedded in Your Investigation Methodology? It is always entertaining watching Safety turn complexity into simplistic discourse. Most recently we have seen a slight change in language about understanding event analysis, investigations and event review. It is good that the … [Read more...] about What Theory of Learning is Embedded in Your Investigation Methodology?
We need to make sure this can never happen again
We need to make sure this can never happen again Can you picture this scenario? Manager: So Ben, I’ve just read through the incident report and I see you injured your back when you ran the forklift into the bollard. I need to ask you a few questions as we need to make sure this type of incident … [Read more...] about We need to make sure this can never happen again
The Link Between Think and Blink
The Link Between Think and Blink I attended another engaging ‘thinking group’ meeting this morning on the Central Coast of NSW in Australia. The meeting was organised by James Ellis, and some new ‘thinkers’ joined us at today’s meeting including; a clinical psychologist who also practices in … [Read more...] about The Link Between Think and Blink
A Much Better Way To Think About Incident Investigations
I’ve recently seen and done a few incident investigations which really fell short of any mark except for ticking the box on the form that says ‘investigation completed’. There are ongoing debates about whether ICAM is better than TapRoot or if that is better than Root Cause Analysis or BowTie or … [Read more...] about A Much Better Way To Think About Incident Investigations
SEEK Investigations Workshop
SEEK Investigations Workshop 5,6,7 July Canberra The next SEEK Investigations Workshop is in Canberra on 5-7 July at the Balcony Room, Tuggeranong Community Centre, Canberra. This is a great opportunity to experience a new and holistic way of investigations in the framework of the Social … [Read more...] about SEEK Investigations Workshop