Five years ago, I launched this website with a series of articles about the Nimrod XV230 disaster.
Today, on the 15th anniversary of this tragedy, I’d like to reflect on the key recommendations. From the subtitle of the independent Review – “A failure of leadership, culture and priorities” – it’s obvious that there may be lessons for us all. The question is, have we learned these lessons?
Trevor Kletz was a safety hero. Over a career spanning nearly 70 years, his thoughts on human factors, human error and accident investigation helped to move the industry from a focus on individual behaviour to organisational and system failures. His proposal that we should shift from blame to learning is the basis of current safety thinking.
12 questions to ask in an investigation – getting behind the label of ‘human error’
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 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.
Discusses the parallels between the Nimrod incident and healthcare
The first of several articles related to organisational failures highlighted in The Nimrod Review