This article was prompted by the 2019 television drama series ‘Chernobyl’, and focuses on human error, safety culture and designing for safety. It provides some discussion points to engage with your key stakeholders and to facilitate safety moments.
The UK NHS (National Health Service), like healthcare in other countries, is a complex system. It is one of the largest employers in the world – some NHS Trusts employ around 20,000 staff and have a turnover of more than £1 billion. The NHS is not a single organisation – there are many parts that make up the NHS. However, these components do not operate as separate entities, they are interconnected and work together as a system. This creates challenges for those that lead these organisations. A recent report on leadership by The King’s Fund: “Leadership in today’s NHS: Delivering the impossible” questions whether senior leadership roles in the NHS are still “do-able”.
Could you be killed by a car tonight? You’re perhaps thinking that I’m referring to a road traffic accident – as an occupant in a vehicle, or maybe as a pedestrian or cyclist. But there’s another way that you could be killed by a car tonight – YOUR car in fact. And this isn’t a reference to the Stephen King novel “Christine”, about a car apparently possessed by supernatural forces. This article examines how a technological change has led to tragedy. Please share this “safety moment” with family, friends and colleagues.
How do we “think”? And what’s the role of Working Memory in thinking?
Little has been written about Working Memory in relation to human performance in the workplace – and so in this article I introduce the concept of working memory, discuss why it’s important and provide some advice on managing it’s limitations.
12 questions to ask in an investigation – getting behind the label of ‘human error’
This article highlights some common misconceptions about fatigue and sleep. Fatigue can lead to poor performance on tasks which require attention, decision-making or high levels of skill.
Around the world, children die from hyperthermia every year after parents unintentionally left them in a hot vehicle, often for a full day.
This post examines these tragedies from a human factors perspective, and provides some tips to prevent it happening to your family.
It also asks whether we can learn from these events to improve human performance in the workplace.
A significant proportion of road accidents involve driver distraction. Many drivers admit to making calls, reading or writing messages, and checking social media whilst driving.
Using mobile phones can cause drivers to take their eyes off the road, their hands off the steering wheel, and their minds off the road and the surrounding situation.
This article outlines how using a mobile can affect driving behaviours, and increase crash risk (even if using a hands-free device).
What is human factors? Do you have difficulty explaining the topic to others? And what value does human factors add?
This post examines the factors that might influence a control room operator’s behaviour (Homer Simpson) and how we might improve his human reliability.
These ‘Performance Influencing Factors’ are key to optimising human performance. The post provides a definition of human factors: “making it easy for Homer to do the right thing”.
Human error is a central concept in ergonomics and human factors. But what is ‘human error’? Is it helping us to improve safety? The language we use may be preventing us from learning or improving.
This post discusses a better way of thinking about human error.
I find these ten facts about human failure a great way to engage delegates on human factors training courses.
This post also discusses Performance Influencing Factors, the things that make human failures more or less likely.
I was heavily influenced by a HSE publication ‘Organising for Safety’, led by Dr Donald Broadbent. This post provides a key conclusion from this report and considers its relevance over 20 years later.
Violations of procedures are a significant cause of many workplace accidents. This post introduces this type of human failures and includes a Briefing Note with strategies to prevent violations.
Nimrod XV230 was due to a catalogue of organisational failures and the lessons are relevant to any high-hazard or complex organisation.
This blog provides ten questions to help stimulate discussion and reflection on leadership, culture and priorities.
Discusses the relationship between complexity and system failures. The author of The Nimrod Review, The Hon. Mr Justice Haddon-Cave, states that simplicity is your friend and complexity is your enemy.
Organisational change is inevitable, but does it have to lead to disaster? Whatever it is that defines ‘safety’ for your organisation, whether that is keeping chemicals in the pipes, keeping trains on the tracks, airplanes in the sky, or not harming patients; it is essential that any significant organisational changes are assessed for their impact on safety. This will include assessing changes to: roles and responsibilities, organisational structures, reporting relationships, staffing levels, staff location, outsourcing, use of contractors, delayering, downsizing and centralisation of functions. This article discusses two aspects of any change that need to be assessed and managed.
“Normalisation of deviance” is when deviations from agreed standards or working practices become incorporated into the routine.
Small changes, slight deviations from the norm, gradually become the norm.
This post provides guidance on identifying and managing such deviations before they become the new ‘normal’.
Expect the unexpected. Past success can lead to complacency. How can organisations become mindful?
Discusses the parallels between the Nimrod incident and healthcare
The first of several posts related to organisational failures highlighted in The Nimrod Review