Tags » Just Culture

Learn your lessons (or crash and burn)

(this article was first posted at eSocSci.org.nz)

On 31 October 2014, the world’s first commercial passenger space ship crashed, killing the co-pilot and seriously injuring the pilot. 1,373 more words

Human Factors

The Straits Times: Doctor fined $2k for chemo-drug error

In this conservative society of Singapore, we don’t often hear about medical mistakes from the newspapers, but they do happen, such as this article from the Straits Times. 671 more words


Lessons from a Cat

After three years of amazing litter box use (she even went in the litter box to cough up hairballs), my cat Muffin looked me in the eye and pooped right on a rug outside of her litter box. 326 more words

Human Factors

How Much Are You Willing to Risk?

 (Edit: Lapse made while typing in the title, I missed a ‘You’ out. See, we are all human!)
I have just finished reading a chapter in Daniel Kahneman’s “Thinking. 801 more words


Blameless RCA

Let ye without failure cast the first stone.

I am involved in a workgroup at work that is exploring Root Cause Analysis in the hopes that we can come up with a way to help everyone improve their RCA process and procedures.

553 more words

Destructive Goal Pursuit, or not knowing when to say stop

Destructive goal pursuit is the inability to stop an activity because the goal is so important (especially in the eyes of the leader) that it takes precedence over everything. 486 more words


Technical Solution, New Process/Rule or Behavioural Change? - LFI Seminars Part 1

I recently attended a seminar in London where the aims of the sessions were to understand how different organisations and individuals learned from incidents. Those attending included legal professionals, Health and Safety experts, academics covering safety, behaviour and learning and operators / industry including construction, maritime and oil & gas. 646 more words