On 23 March 2005, a massive explosion and fires killed 15 people and injured another 180 at the BP Texas City Refinery, Texas. This disaster led to many investigation reports. It has been said that BP failed to learn from numerous warning signs that could have prevented the disaster. Many years later, I question how much wider industry has learnt - and provide a reflection toolkit based on 12 quotes from the investigations.
There are nine key principles that organisations can apply to capture the human contribution to adverse events. These principles will help you to apply human factors in the investigation process. They also demonstrate how organisations learn (and fail to learn) from adverse events.
The design of work and workplaces can have a significant impact on our lives, including contributing to the causes of suicide. Employers have a duty to manage work-related factors that can impact on suicide-related thoughts. "Beyond Now" is an app created by Beyond Blue to support people through these feelings.
I'm really pleased to announce that this website is the joint winner of the Outstanding Communications Award 2021 from the UK Chartered Institute of Ergonomics and Human Factors. Writing content and maintaining the site takes considerable effort, but recognition like this keeps me motivated to continue producing materials. Thank You !!
The 'ironies of automation' refers to a set of unintended consequences as a result of automation, that could detrimentally affect human performance on critical tasks. Automation might increase human performance issues, rather than eliminate them.
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.
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. In this article, I discuss 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. In this article I provide 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.
Here's some guidance on identifying and managing such deviations before they become the new 'normal'.