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.
Human factors: Preventing violations
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.
Ten questions on organisational failures
Nimrod XV230 was due to a catalogue of organisational failures and the lessons are relevant to any high-hazard or complex organisation. In this article I provide ten questions to help stimulate discussion and reflection on leadership, culture and priorities.
Keep it simple
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.
Change is the only constant
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
"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.
Here's some guidance on identifying and managing such deviations before they become the new 'normal'.
Success, complacency and failure
Expect the unexpected. Past success can lead to complacency. How can organisations become mindful?
Nimrod XV230: Parallels with healthcare
Discusses the parallels between the Nimrod incident and healthcare
What can you learn from the Nimrod disaster?
The first of several articles related to organisational failures highlighted in The Nimrod Review
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