Book

Close calls: Managing risk and resilience in airline flight safety

Authors:

Abstract

Drawing on extensive and detailed fieldwork within airlines-an industry that pioneered near-miss analysis- this book develops a clear set of practical implications and theoretical propositions regarding how all organizations can learn from 'near-miss' events and better manage risk and resilience.
... Prior theoretical approaches to organizational risk in sociotechnical systems consider errors, failures, and fluctuations to be inherent to all organized activity, and therefore focus on the organizational mechanisms needed to prevent or recover from disruption (Pettersen Gould, 2021;Rasmussen, 1990;Reason, 1997;Roe & Schulman, 2008). These mechanisms are typically conceptualized as safety defenses or barriers (Hollnagel, 2004;Reason, 1990;Svenson, 1991)-ranging from "hard" defense such as physical barriers or multiple back-up systems to "soft" defense such as procedural controls or training programs (Reason, Hollnagel, & Paries, 2006)-or as capacities for resilience that enable rapid identification and flexible adaptation to unexpected events (Hollnagel, Paries, Woods, & Wreathall, 2012;Macrae, 2014a;Wiig et al., 2020). Defenses and adaptations will themselves always be partial or fallible, with weaknesses arising from latent organizational factors such as poorly designed equipment or inadequate resourcing. ...
... Or, as one concerned Uber manager bluntly recommended a few days before the fatal accident, "do not drive the cars more than is necessary" (Efrati, 2018c). Managing risk in AIS will therefore depend on developing more sophisticated ways of assessing and managing the mechanisms that underpin social and organizational learning (Macrae, 2014a(Macrae, , 2014bWaterson, 2020), just as much as it depends on developing more sophisticated mechanisms of machine learning (Stilgoe, 2018). ...
... A core component of this should be event recorderslike the "black boxes" used in the aviation industrythat capture rich, real-time information about AIS processes before and during accidents (Murphy & Woods, 2009;Winfield & Jirotka, 2017). The analysis here also emphasizes the importance of expanding the focus and mechanisms of event recording in AIS to capture more minor safety disruptions from a Core components of an infrastructure for governing safety, managing risk and learning from autonomous and intelligent system failures diverse range of sources-such as routine operational monitoring systems that identify and record deviations from predetermined safety standards, equivalent to the continuous safety monitoring programs used in airlines (FAA, 2004;O'Leary, Macrae, & Pidgeon, 2002), as well as nonpunitive incident reporting systems for professionals and the public to report safety events and "near-miss" incidents (Macrae, 2014a(Macrae, , 2016McGregor, 2020). These sorts of event recording mechanisms can help to reveal the preconditions of sociotechnical failure, and form the foundational safety data infrastructure that is needed to underpin the epistemic processes of risk management and avoid the emergence of learning lag. ...
Article
Full-text available
Efforts to develop autonomous and intelligent systems (AIS) have exploded across a range of settings in recent years, from self‐driving cars to medical diagnostic chatbots. These have the potential to bring enormous benefits to society but also have the potential to introduce new—or amplify existing—risks. As these emerging technologies become more widespread, one of the most critical risk management challenges is to ensure that failures of AIS can be rigorously analyzed and understood so that the safety of these systems can be effectively governed and improved. AIS are necessarily developed and deployed within complex human, social, and organizational systems, but to date there has been little systematic examination of the sociotechnical sources of risk and failure in AIS. Accordingly, this article develops a conceptual framework that characterizes key sociotechnical sources of risk in AIS by reanalyzing one of the most publicly reported failures to date: the 2018 fatal crash of Uber's self‐driving car. Publicly available investigative reports were systematically analyzed using constant comparative analysis to identify key sources and patterns of sociotechnical risk. Five fundamental domains of sociotechnical risk were conceptualized—structural, organizational, technological, epistemic, and cultural—each indicated by particular patterns of sociotechnical failure. The resulting SOTEC framework of sociotechnical risk in AIS extends existing theories of risk in complex systems and highlights important practical and theoretical implications for managing risk and developing infrastructures of learning in AIS.
... the AAIB). 63 Such distinction between investigating and implementing teams may, on the face of it, seem contradictory to the concept of a participatory approach but this need not be the case. As shown in qualitative studies involving investigators from numerous non-healthcare settings, 243 organisations without undue influence from organisational management. ...
... This independence allowed them to give recommendations to organisations at all levels (from regulatory bodies to airlines) without risking conflicts of interest. 63 Stronger risk controls can also be achieved through a better understanding of human factors, as shown in the context of healthcare by Canham et al. 237 The authors highlighted the importance of having human factors expertise when using systemsbased methods of incident analysis and when formulating risk controls following investigations. 237 They found that investigations using system-based methods, as described in section 6.2.1.1 and facilitated by human factors specialists, resulted in the formulation of more risk controls at the system level when compared with traditional root cause analysis led by those without the required expertise. ...
... Examples in the literature include mentoring and professional networks. 27,63 The distinction between formal and informal learning practices is not always clear. For example, informal sharing of lessons learnt between employees can follow on from many formal centrally coordinated learning activities. ...
Thesis
Full-text available
Improving risk controls following root cause analysis of serious incidents in healthcare- Mohammad Farhad Peerally Background Root cause analysis (RCA) is widely used following healthcare serious incidents, but does not necessarily lead to robust risk controls. This research aimed to examine current practices and to inform an understanding of what good looks like in formulating and implementing risk controls to improve patient safety. Methods First, I undertook a content analysis of 126 RCA reports over a three-year period from an acute NHS trust, with the goals of characterising (i)the contributory factors identified in investigations and (ii)the risk controls proposed in the action plans. Second, I conducted a narrative review of the academic literature on improving risk control practices in safety-critical industries, including but not limited to healthcare. Finally, I undertook a qualitative study involving 52 semi-structured interviews with expert stakeholders in post-incident management, analysed using the framework method. Results: Content analysis of serious incident investigation reports identified the preoccupation of RCAs with identifying proximate errors at the sharp end of care, neglecting wider contexts and structures. Most (74%) risk controls proposed could be characterised as weak and were poorly aligned with identified contributory factors. Together, the narrative review and the findings of the interview study suggested eleven features essential to addressing these problems: systems-based investigations; a participatory approach, skilled and independent investigators; clear and shared language; including patients’ views; allocating time and space to risk control formulation; adding structure to risk control formulation; sustainable risk controls mapped to identified problems; purposeful implementation and better tracking of risk controls; a collaborative approach to quality assurance and improved organisational learning. Discussion and conclusion: RCAs as currently conducted, and the action plans that arise from them, are often flawed. The eleven features identified will be important in improving risk control formulation and implementation. To operationalise these features, there is a need for: professional and independent investigations, risk controls based on a sound theory of change, and improved cultures and structures for organisational learning.
... We use SOTEC as a conceptual paradigm to identify risk scenarios and create corresponding regulatory requirements needed to mitigate these risks. Leveraged in this way, it operates as an instrument to challenge technical routines and organizational understandings, practices, and cultures (Huber & Rothstein, 2013;Macrae, 2014Macrae, , 2022Perrow, 1999). ...
... In order to avoid a culture of research communication that deemphasizes the importance of having an integrated, proactive, and centralized system for risk management, we argue that developmental disintegration can be tied to a specific regulatory requirement, namely, the project of "merging development activities," in the form of developers and operators ensuring that there is proactive coordination between the multiple teams involved in different development and application activities. This inevitably involves work on multiple fronts, ranging from measures to shape or monitor organizational cultures (Downer, 2010) to stylized and mandated procedures for sharing and receiving certain types of information (Macrae, 2014). For instance, creating a culture that privileges the rapid and wide distribution of simulation and real-world information and prioritizes consistent safety oversight and assurance pathways across various stakeholders (researchers, operators, and policymakers). ...
Article
Full-text available
The past decade has seen efforts to develop new forms of autonomous systems with varying applications in different domains, from underwater search and rescue to clinical diagnosis. All of these applications require risk analyses, but such analyses often focus on technical sources of risk without acknowledging its wider systemic and organizational dimensions. In this article, we illustrate this deficit and a way of redressing it by offering a more systematic analysis of the sociotechnical sources of risk in an autonomous system. To this end, the article explores the development, deployment, and operation of an autonomous robot swarm for use in a public cloakroom in light of Macrae's structural, organizational, technological, epistemic, and cultural framework of sociotechnical risk. We argue that this framework provides a useful tool for capturing the complex “nontechnical” dimensions of risk in this domain that might otherwise be overlooked in the more conventional risk analyses that inform regulation and policymaking.
... In this context, where multiple organizations or groups interact, indicators can be conceived as boundary objects (Star and Griesemer, 1989), facilitating communication about the reliability and safety of system performance, and inviting collective examination of risks in ways that may not otherwise take place (Macrae, 2014). Conceptualizing artefacts-such as safety performance indicators-as boundary objects that have meaning in more than one social world provides a useful way to consider how the tensions between different actors and viewpoints of safety may be negotiated or resolved. ...
... The notion of boundary objects has been used in a range of qualitative and ethnographic research particularly in the field of organization studies, in the sociology of science and technology and in knowledge management (see Trompette and Vinck (2009) for a detailed review) and increasingly in health and safety-related studies (Macrae, 2014). The theory has proven to be a useful way to consider how tensions between different actors and viewpoints are negotiated and resolved. ...
... A more productive and practical image to guide the governance of AI safety is not that of the Blade Runner, but is rather more prosaic, less familiar though much better understood-that of the 'Tin Kicker': air crash investigators who 'kick tin' on accident sites while picking over wreckage (Byrne 2002;Nixon and Braithwaite 2018). Professional accident and safety investigators have been central to the continuous improvement of flight safety since the dawn of aviation (Macrae 2014). The first independent air crash investigation was conducted in 1912 (Hradecky 2012), followed soon after by the establishment of the UK's accident investigation body in 1915 (AAIB 2021). ...
... Rather than seeking accountability for past failures, it is exclusively learning-oriented and purposefully does not attribute liability or blame but instead seeks to create active accountability for future improvement (Braithwaite 2011). Rather than focusing on compliance with accepted standards, it is concerned with understanding the practical realities of complex systems, and why unexpected or deviant behaviours may be situationally rational and adaptive given particular contexts, constraints and affordances (Macrae 2014). And rather than a closed and covert process, it is fundamentally participatory, openly engaging with all relevant stakeholders to collaboratively understand reasons for failure and develop appropriate recommendations for improvement-whilst retaining authority over those findings and recommendations (Macrae and Vincent 2014). ...
... Safety-critical industries have developed sophisticated systems to support these activities of investigation and learning at all levels. These range from lengthy investigations of major accidents that are coordinated by national investigative bodies to relatively rapid local-level investigations of more minor incidents or nearmiss events that are conducted by investigators within individual organisations [21]. A lot of media attention understandably focuses on the investigations into highprofile accidents that are conducted by national investigation bodies, such as the US National Transportation Safety Board's investigations of the various accidents involving semi-automated Tesla vehicles [4] and Uber's autonomous test vehicle [5]. ...
... However, much of the more routine work of investigation actually occurs within individual organisations, like airlines and hospitals, which regularly conduct hundreds or thousands of investigations each year. These local-level investigations examine more minor safety incidents as well as near-miss events -where there was no adverse outcome but some sort of safety-relevant failure was detected, such as a poorly specified maintenance procedure in an airline leading to a technical failure that causes a rejected take-off [21]. Local-level investigations employ similar methods and approaches to those conducted at a national level, but are often much more rapid, lasting days or weeks rather than months and years. ...
Chapter
Full-text available
Robot accidents are inevitable. Although rare, they have been happening since assembly line robots were first introduced in the 1960s. But a new generation of social robots is now becoming commonplace. Equipped with sophisticated embedded artificial intelligence (AI), social robots might be deployed as care robots to assist elderly or disabled people to live independently. Smart robot toys offer a compelling interactive play experience for children, and increasingly capable autonomous vehicles (AVs) offer the promise of hands-free personal transport and fully autonomous taxis. Unlike industrial robots, which are deployed in safety cages, social robots are designed to operate in human environments and interact closely with humans; the likelihood of robot accidents is therefore much greater for social robots than industrial robots. This chapter sets out a draft framework for social robot accident investigation, a framework that proposes both the technology and processes that would allow social robot accidents to be investigated with no less rigour than we expect of air or rail accident investigations. The chapter also places accident investigation within the practice of responsible robotics and makes the case that social robotics without accident investigation would be no less irresponsible than aviation without air accident investigation.
... Further to the work of Brizon and Wybo (2009), a considerable number of OSH researchers have also argued that the development and use of a structured weak signals management process within occupational environments is faced with significant human and organizational barriers. Macrae (2009Macrae ( , 2014a, highlighted the fact that occupational environments are complex, chaotic, and noisy, to begin with. Therefore, distinguishing signal from noise and recognizing the early signs of risk or, in other words, weak signals and threats, is a significant challenge. ...
... As it is commonly known, airlines utilize structured incident reporting systems which are being handled by flight crew, ground crew, cabin crew and engineers. This personnel is obliged to submit or 'raise' reports to notify investigators of any operational mishap or safety event, according to set reporting criteria (Macrae, 2014a). As the aviation occupational environment is rich with various types of ambiguous signs and possible warnings of potentially unknown risks (which fit into the concept of 'weak signals'), such signals are being systematically monitored and recorded for risk assessment and standardization purposes in order to understand whether they may indicate some serious underlying threat (Macrae, 2009;Sjöblom et al., 2013). ...
Article
The domain of occupational safety and health (OSH) is forced to respond to the requirements set by the rapid technological development and progress in order for the organizations to attain acceptable organizational safety and health maturity levels. Being able to understand weak signals and to develop mechanisms for their identification and management, can potentially lead to safer and healthier workplaces. The systematic and on-time identification of weak signals and their origin provides the potential for early intervention. If the threat is not recognized at an early stage, then the possibility of successful intervention is minimized along with the potential to abolish unwanted consequences and impending major disasters. This paper investigates and analyzes the current knowledge and use of weak signals within the OSH domain. The investigation is primarily based on the review of existing OSH literature, and is supplemented by a technical examination of selected major industrial accidents with respect to the documented existence of weak signals before their occurrence. The findings of this investigation provide a theoretical contribution towards a better understanding of the nature and current impact of weak signals within the OSH domain. Furthermore, they highlight the lack of weak signals consideration within traditional occupational health and safety management systems (OHSMS), and indicate that their explicit management can potentially enhance the global effort made for the minimization of occupational accidents, diseases and dangerous occurrences.
... Safety-critical industries have developed sophisticated systems to support these activities of investigation and learning at all levels. These range from lengthy investigations of major accidents that are coordinated by national investigative bodies to relatively rapid local-level investigations of more minor incidents or nearmiss events that are conducted by investigators within individual organisations [21]. A lot of media attention understandably focuses on the investigations into highprofile accidents that are conducted by national investigation bodies, such as the US National Transportation Safety Board's investigations of the various accidents involving semi-automated Tesla vehicles [4] and Uber's autonomous test vehicle [5]. ...
... However, much of the more routine work of investigation actually occurs within individual organisations, like airlines and hospitals, which regularly conduct hundreds or thousands of investigations each year. These local-level investigations examine more minor safety incidents as well as near-miss events -where there was no adverse outcome but some sort of safety-relevant failure was detected, such as a poorly specified maintenance procedure in an airline leading to a technical failure that causes a rejected take-off [21]. Local-level investigations employ similar methods and approaches to those conducted at a national level, but are often much more rapid, lasting days or weeks rather than months and years. ...
Preprint
Full-text available
Robot accidents are inevitable. Although rare, they have been happening since assembly-line robots were first introduced in the 1960s. But a new generation of social robots are now becoming commonplace. Often with sophisticated embedded artificial intelligence (AI) social robots might be deployed as care robots to assist elderly or disabled people to live independently. Smart robot toys offer a compelling interactive play experience for children and increasingly capable autonomous vehicles (AVs) the promise of hands-free personal transport and fully autonomous taxis. Unlike industrial robots which are deployed in safety cages, social robots are designed to operate in human environments and interact closely with humans; the likelihood of robot accidents is therefore much greater for social robots than industrial robots. This paper sets out a draft framework for social robot accident investigation; a framework which proposes both the technology and processes that would allow social robot accidents to be investigated with no less rigour than we expect of air or rail accident investigations. The paper also places accident investigation within the practice of responsible robotics, and makes the case that social robotics without accident investigation would be no less irresponsible than aviation without air accident investigation.
... Many of these are contested and debated in the existing literature [2]. This is perhaps because resilience is primarily a guiding concept used in a range of fields and research traditions, from psychiatry and understanding of individual human response to stress, to societal planning and understanding of response and recovery from large scale disasters, to biology and understanding of resilience in organisms and ecological system functioning [3][4][5]. Resilience has also become a key concept in safety research. Over the past 10-15 years, 'resilience engineering' has become an accepted domain within safety science and has attracted considerable interest by advocating for new ways of understanding work processes in complex adaptive sociotechnical systems [2,[6][7][8][9]. ...
... The healthcare quality concept integrates subdimensions of clinical effectiveness, patient safety, patient centeredness, care coordination, efficiency, timeliness, and equity [30][31][32][33]. In the literature, resilience is often seen in relation to risk with the aim of preventing risk from manifesting into accidents or harm, and to recover from these [5]. While the safety and risk literature generally limit considerations of resilience to the safety dimension of quality, we propose that the boundary should be wider in healthcare. ...
Article
Full-text available
Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme. Main text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience. Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.
... Revisiting the organisational and cultural principles that support this in other industries still offers salient lessons, primarily the need for well resourced safety teams led by experts that allow systematic examination of practical work and the development of robust system level improvements in contexts removed from fear and blame. 24 ...
... 27 But above all, perhaps one of the most striking and fundamental lessons for healthcare is the extent to which other industries allocate considerable resources and dedicated staff to systems analysis and quality improvement. 24 Box 2: Integrating systems analysis, decision making, and cognitive aids ...
... Once the accident/incident investigation has concluded, its recommendations must be implemented prior to redeployment of the swarm robotic system and resumption of operation. It is important to note that those recommendations 5 In aviation, there is strong evidence that the thorough investigation of near-misses has significantly improved safety [28]. 6 Perhaps the unexpected behaviours are localized to a small cluster of robots in which case those robots can be extracted while the rest of the swarm continues to operate. ...
Article
Full-text available
In this paper, we address the question: what practices would be required for the responsible design and operation of real-world swarm robotic systems? We argue that swarm robotic systems must be developed and operated within a framework of ethical governance. We will also explore the human factors surrounding the operation and management of swarm systems, advancing the view that human factors are no less important to swarm robots than social robots. Ethical governance must be anticipatory, and a powerful method for practical anticipatory governance is ethical risk assessment (ERA). As case studies, this paper includes four worked examples of ERAs for fictional but realistic real-world swarms. Although of key importance, ERA is not the only tool available to the responsible roboticist. We outline the supporting role of ethical principles, standards, and verification and validation. Given that real-world swarm robotic systems are likely to be deployed in diverse ecologies, we also ask: how can swarm robotic systems be sustainable? We bring all of these ideas together to describe the complete life cycle of swarm robotic systems, showing where and how the tools and interventions are applied within a framework of anticipatory ethical governance. This article is part of the theme issue ‘The road forward with swarm systems’.
... Quality of health services includes clinical effectiveness, safety, patient, patient-centered care, continuity of care, timely care, efficiency, and justice. However, the resilience of health service quality becomes apparent when the quality of services is subject to challenges, and the conditions are prone to changes (4,5). The World Health Organization emphasizes the importance of delivering and continuing quality healthcare services (6 2 words, hospitals should be able to have the best accountability and performance in providing quality health services in stressful situations and adverse conditions, as they do in normal conditions (7). ...
Article
Full-text available
Background: Ensuring and maintaining people’s health is one of the most important programs in every country. The aim of the present study was to identify successful experiences of hospital service quality resilience during the coronavirus pandemic. Methods: The present qualitative study was conducted using a content analysis method from September 2021 to April 2022. Seventeen senior and middle managers of Shiraz University of Medical Sciences and affiliated hospitals assigned as coronavirus centers were purposefully included. Data were analyzed using Graneheim and Lundman's method and MAXQDA 2020 software. The results of this study identified successful experiences that affected the quality of hospital services during the pandemic. Results: Five main themes were identified:" Supporting University of Medical Sciences, Improving the hospital process, human resource, Medical, and pharmaceutical equipment and Welfare Facilities" and 31 sub-themes. Conclusion: The resilience of hospital service quality was one of the governing indicators of the Ministry of Health during the coronavirus pandemic. Despite the many challenges in pandemic management and control, hospitals have made efforts in this field to create successful experiences that make it even more important to prepare hospitals for new epidemic conditions.
... Reason (1997) suggested that a safety culture has five elements including being 'just.' Organisations agreed that 'just' was needed to encourage reporting, but without absolving individuals of their responsibilities (Macrae, 2014). It was evident that the maturity of safety, and of safety cultures, varied across industries, within industries and within organisations. ...
Conference Paper
The aim of this study was to understand how the transport industries of aviation, rail and maritime have implemented near-miss management systems, and the impact of their learning from near misses. Grounded Theory, augmented by a scoping review, was used to generate the theory and principles behind how the industries manage near misses. The paper summarises the key findings from the scoping review and the themes identified through interviews with safety/human factors leads across various transport organisations. The findings provide insights into how healthcare might better manage near misses. However, the findings also challenge healthcare perceptions that other industries have perfected safety, and the specific value of near misses if used in isolation. The paper finishes by recommending safety management systems in healthcare.
... Some have considered the diversity of conceptualisations on resilience a weakness of the traditional approach giving rise to growing calls for a coherent integrative theoretical framework of resilience (Hudson, 2003;Murray, 2018;Thibaud et al. 2018). No single theory on resilience can address all the relevant factors and concepts that fall into the picture (Macrae 2014;Torques et al. 2017). Mapping out the general contours of a broad and expansive framework may act as a useful coordinating platform of future work on resilience in the highrisk industries. ...
Thesis
Rural areas in Zimbabwe, as elsewhere, are undergoing various transformations, some induced by natural processes and others by human interventions. One has to acknowledge the increase anthropogenic actions on the Earth since the 1950 that have partly triggered the challenges facing the planet. Infusion implies a deliberate mainstreaming with debates, practices and policies of an agenda. In this case, in education, health, social policy directions and related matters, resilience thinking needs to be the bottom line of discussion. That away positive results are expected. This thesis contributes to the debate on planning, development and management of rural settlements under the impact of environmental disasters largely induced by climate change. The thesis suggests measures towards the infusion of disaster resilience thinking and practice in rural settlement planning. Publications in the study are informed by various methodologies, including literature review, archival, fieldwork, interviewing and surveys. The thesis is structured into four major sections. The first section, Section A covers Preliminary Pages of the thesis that include Dedication, Preface, Executive Summary and Abstracts of Publications and Acknowledgements. The second section, Section B is Introduction, Literature and the Study Local Context and covers three chapters, Chapter 1, the Introduction, Chapter 2, Natural Disaster Resilience, Rural Settlement Planning and Housing: A Literature Review and Chapter 3, Understanding Zimbabwe: Disaster Resilience Thinking and Practice and Rural Settlement Planning, Development and Management. The third section, Section C (see also Appendix 1) contains the articles and publications. Under this section, three categories of publications are presented, A, B and C. A are those papers that speak to the situation analysis regarding the incident of climate change and environmental challenges as they reflect in the rural areas. B speaks to those papers that try to speak to measurement and indicators of climate resilience plus global and regional experiences in the same. The C category speaks to possible options and initiatives that can be done for rural disaster resilience practice enhancement. The last section is Section D entitled Study Synthesis, Conclusion and Options. Quite apparent in the foregoing discussion and thesis is the acknowledgement that disasters and risks with the paraphernalia of their impacts are growing to be part and parcel of life at a global scale. As such resilience thinking is the way to. The buffeting shall continue but systems have to be proofed and designed that the readiness is always in place. Preparing for disasters and risks begins by the general awareness, followed by a deliberate step in putting ‘cushions’ in place. A collaborative approach is required. In the thesis, the study has demonstrated that the players are many and includes individuals, organised (and unorganised communities, divided by aspects of gender, age, professionalism, spatial boundaries, etc, government (local and central) and non-state actors (community – based organisation and corporates). There have different capacities and contributions to the debate and practice of resilience, mitigation and adaption. These players should have a principal agenda of tapping on the diversity to bring solution to different scales of intervention – site, community, district or precinct, regional, national or even international. They have to live above besetting politics towards creating consensus for wise action. The study proposes an 8Ss Model for inculcating resilience thinking and practice in rural settlement planning and management as a strategy for managing disaster risk.
... Safety voice is shown to be a multi-dimensional construct, with behaviors attempting to prevent hazards, promote safety improvements, prohibit unsafe activity, and express general dissatisfaction Bienefeld and Grote 2014;Curcuruto et al. 2020). Second, incident reporting, which focuses on employees submitting reports about accidents, near-misses, or safety concerns to their organization (Macrae 2014a). Incident reports are distinct from safety voice due to their formality (i.e. using an institutional procedure), and data are conceptualized as essential for monitoring risk, capturing errors, and supporting organizational learning (e.g. from past incidents). ...
Article
Full-text available
Safety communication relates to the sharing of safety information within organizations in order to mitigate hazards and improve risk management. Although risk researchers have predominantly investigated employee safety communication behaviors (e.g. voice), a growing body of work (e.g. in healthcare, transport) indicates that public stakeholders also communicate safety information to organizations. To investigate the nature of stakeholder safety communication behaviors, and their possible contribution to organizational risk management, accounts from patients and families – recorded in a government public inquiry – about trying to report safety risks in an unsafe hospital were examined. Within the inquiry, 410 narrative accounts of patients and families engaging in safety communication behaviors (voicing concerns, writing complaints, and whistleblowing) were identified and analyzed. Typically, the aim of safety communication was to ensure hospital staff addressed safety risks that were apparent and impactful to patients and families (e.g. medication errors, clinical neglect), yet unnoticed or uncorrected by clinicians and administrators. However, the success of patient and family safety communication in ameliorating risk was variable, and problems in hospital safety culture (e.g. high workloads, downplaying safety problems) meant that information provided by patients and families was frequently not acted upon. Due to their distinct role as independent service-users, public stakeholders can potentially support organizational risk management through communicating on safety risks missed or not addressed by employees and managers. However, for this to happen, there must be capacity and openness within organizations for responding to safety communication from stakeholders.
... A proper design would require a state of art technique and true ingenuity to reach this balance, so dedicated flight test personnel and department would be necessary for large OEM to steady accumulate flight capability and their opinion has to be respected by management level to reach a full success for the project. Another possible solution to this contradictory topic is through risk management [14]. ...
Conference Paper
Full-text available
This paper wants to discuss flight test in a system engineering manner to analyze and understand relation, activities and behavior in flight test, then make suggestions to make it more safe and efficient, thus generate high quality aircraft product. The paper will use some methods in model-based system engineering (MBSE) [1] such as stake holder identification and scenario analysis. Then flight test planning and management, enabling tools/methods and flight test role in system engineering V-model are discussed while suggestions are made based on commercial aircraft flight test characteristics.
... A continuous risk monitoring approach that begins with identifying likelihood, severity, and early involvement is key to averting and reducing the impact of disruption and risk on the supply chain as well as the overall operations of the enterprise (FAA, 2009). Risk responsiveness is about an airline's ability to protect and recover its operation from the potential human errors and natural disasters (Macrae, 2014;Sheffi, 2005). Thus, the first study for the risk management of airlines is the relationship between risk monitoring and risk responsiveness. ...
Article
Full-text available
The focus of this research is an analysis of U.S.-based airline employees' responses to corporate preparedness for the COVID-19 disruptions to domestic and international airline operations. A survey was issued during May and June 2020 to U.S.-based employees of major and national carriers and U.S.-based employees from foreign carriers. The research project consists of a questionnaire used to answer the key question: What is your perception of your company's preparedness for and response to the COVID-19 outbreak? Sub-questions address three key areas of employees' responses: 1) Was the airline prepared prior to the pandemic? 2). Did the airline respond appropriately to the pandemic? 3) Is the airline positioned well to recover from the pandemic? Findings indicate that airlines' risk management systems are recognized as a weakness in the organizations; however, they are taking steps to enhance their risk management protocols since dealing with the global coronavirus pandemic. Additional findings indicate that air transport companies need to move away from their reliance on the existing risk management system that is based on historical disruptions and toward a more proactive system. The last finding indicates that knowing and understanding the full potential of the impact of pandemics (or epidemics) may be advantageous in recovering business quickly.
... Workplace environments are complex, chaotic, and noisy. Distinguishing signals from noise and recognizing the early signs of risk, is considered to be one of the main challenges in risk management (Macrae, 2009(Macrae, , 2014. According to the study carried out by Nicolaidou et al. (2021) the use of weak signals in OSH environments is currently hindered by the lack of a commonly agreed theoretical description of 'weak signals concept' in terms of its definition and its descriptive parameters, as well as the lack of an integrated approach to the management of weak signals within existing OHSMS systems. ...
Article
The aim of this study is to provide a theoretical contribution towards a better understanding of the nature and impact of weak signals within the Occupational Safety and Health (OSH) domain, and to provide potential directions, regarding the introduction of weak signals management within established Occupational Health and Safety Management Systems (OHSMS), based on a proactive approach. For the purpose of this study, a Delphi method with two iterations was utilized, supplemented by an experts’ focus group discussion, aiming to explore experts’ opinion regarding the potential impact of weak signals management in OSH. The findings of this research, reveal the existence of weak signals prior occupational accidents and other unwanted incidents at workplace, as well as the importance of its on-time management. The outcomes, enhance the development of a clearer definition of weak signals in the OSH domain, the development of a comprehensive weak signals management framework and concurrently, and provide directions for the introduction of weak signals management into existing traditional OHSMS.
... This vast majority of the incidents reporting was of minor clinical significance. While these events can lead to detection of latent errors, large volumes of reports submitted at a macro level can swamp important signals with noise and lead to delays in report processing and dissemination of recommendations [23]. This delay in processing can lead to staff disenchantment and low levels of engagement [11]. ...
Article
Full-text available
IntroductionMedical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system.Methods Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly.ResultsSeventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department.Conclusion Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.
... Established and trusted processes of air accident investigation provide an excellent model of good practice for AIS-processes, which have without doubt contributed to the outstanding safety record of modern commercial air travel (Macrae, 2014). One example of best practice is the aircraft Flight Data Recorder, or "black box"; a functionality we consider essential in autonomous systems (Winfield and Jirotka, 2017). ...
Article
Full-text available
This paper describes IEEE P7001, a new draft standard on transparency of autonomous systems 1 . In the paper, we outline the development and structure of the draft standard. We present the rationale for transparency as a measurable, testable property. We outline five stakeholder groups: users, the general public and bystanders, safety certification agencies, incident/accident investigators and lawyers/expert witnesses, and explain the thinking behind the normative definitions of “levels” of transparency for each stakeholder group in P7001. The paper illustrates the application of P7001 through worked examples of both specification and assessment of fictional autonomous systems.
... A massa de dados, em formato digital, fornecida em cada voo, por exemplo, é inestimável na identificação de novas fontes de riscos, criando oportunidades para reduzir ainda mais os riscos persistentes e avaliar incidentes e acidentes. A análise desses dados tem muita relação com a operação dos sistemas de notificação de incidentes (14). Grandes quantidades de dados automatizados ainda não estão amplamente disponíveis na área de saúde; nem foi aproveitada a oportunidade, em larga escala, de adaptar o monitoramento eletrônico existente no atendimento ao paciente para fins de segurança. ...
Book
Full-text available
É com imensa honra e alegria que apresentamos a versão em língua portuguesa das Orientações da Organização Mundial da Saúde para os “Sistemas de Notificação e Aprendizagem de Incidentes de Segurança do Paciente: Relatório Técnico e Orientações” (título original: “Patient Safety Incident Reporting and Learning Systems: Technical report and guidance.” Geneva: ©World Health Organization; 2020). Esta obra, que contou com a colaboração de mais de 40 especialistas mundiais, está sendo lançada em pleno mês da Campanha Nacional pela Segurança do Paciente, e será de enorme utilida¬de para as vítimas e seus familiares, para os incansáveis trabalhadores da Área da Saúde (médicos, enfermeiros, gestores, entre tantos outros) e também para todos os operadores do Direito envolvidos com o Direito Médico, Gestão de Risco, Governança e Compliance, rumo a um sistema de saúde mais seguro e eficiente. Anualmente, milhares de vidas são ceifadas por conta das falhas nos serviços de saúde e bilhões em recursos são gastos, sem citarmos o enorme sofrimento de pacientes e familiares. Se pudermos colaborar para evitar qualquer sofrimento ou preservar uma vida, já terá valido a pena! Sintam-se à vontade para compartilhar esse material. Disponível em www.fernandoesberard.com Em breve disponível também no site da Editora Mizuno. Forte abraço! Dr. Fernando Esbérard – Perícias Médicas Dra. Daniele Silva do Nascimento – Direito Médico
... Some have considered the diversity of conceptualisations on resilience a weakness of the traditional approach giving rise to growing calls for a coherent integrative theoretical framework of resilience (Hudson 2003;Murray 2018;Thibaud et al. 2018). No single theory on resilience can address all the relevant factors and concepts that fall into the picture (Macrae 2014;Torques et al. 2017). Mapping out the general contours of a broad and expansive framework may act as a useful coordinating platform of the future work on resilience in the high-risk industries. ...
Article
The article makes a case for the integration of resilience thinking in the debate on rural human settlements in the regional planning. It observes the numerous definitions of resilience within different research traditions, disciplines and fields, such as sociology, psychology, medicine, engineering, economics, ecology and political science have affected the decision-making processes in different human settlements across the globe. The dynamics of integrating resilience theory and practice into rural settlement planning and implications for sustainable development are little understood. The paper suggests the broadening of resilience drawing on diverse perspectives that appeal to wide ranging interdisciplinary experiences. Using the multi-case study approach, the article suggests how ideas of resilience can be translated into practice and how practices of resilience can be theorised in the context of the regional planning in Zimbabwe. Undoubtedly, an integrated framework for the development country's space economy should accommodate a wide range of concepts, strategies and models of resilience together with the underpinning policy implementation modalities.
... 8 Safety begins, rather than ends, with incident reports, and requires broad, in-depth and high-quality investigations and careful planning and follow-up of the implementation of corrective actions to ensure they are sustainable over time. 46 To generate persistent knowledge and learning from cases, feedback should include more than a passive, brief report in a staff meeting that reminds of or notifies of the updating of a routine. ...
Article
Full-text available
Objectives To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed. Design and settings Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide. Participants Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316). Primary and secondary outcome measures Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine. Results The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended. Conclusions The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients. The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority’s reports rather than the specific incident type, and that no new service improvements or lessons are being identified.
... Rather there is a complex interaction between a varied set of elements, including human behaviour, technological aspects of the system, sociocultural factors, and a range of organisational and procedural weaknesses [10,11]. ...
Chapter
Full-text available
Fundamental characteristics of healthcare, including approaches to priority-setting, culture, traditions of professional practice, leadership styles, and accountability mechanisms mean that many deep-seated causes of unsafe care have proved intractable to transformation. The wisdom and experience of patients and families that have suffered harm is enormous and should be better harnessed. The World Health Organization has led a diverse range of global action on patient safety over two decades. This has been highly successful in promoting interest, understanding, and commitment as well as driving specific programmes of action throughout the world. The organisation has also played a powerful convening role in bringing experts, organisations, and countries together to discuss and plan initiatives. This focus must be maintained in the face of slow and inconsistent improvement.
... Consequently, there are well-established institutional/management strategies, collaborations, and practices associated with preventing incidents and accidents. Maintaining the efficacy of these approaches is viewed as important for protecting hazardous technologies, as they are based on previous incidents and include the dynamic yet fragile organizational web of safety defenses [24]. From the 1980s, supported by an increased understanding of how and why accidents happen, increased attention was paid to how accidents and disasters are caused by societal developments [6]. ...
Chapter
Full-text available
This chapter looks back at how safety and security have developed in hazardous technologies and activities, explaining what has become an intersection between the two in both strategies and management practices. We argue for the connection to be made between social expectations of safe and secure societies and the limits to management and technical performance. In the first part of the chapter, conceptual similarities and differences are addressed and we distinguish three scientific and contextual vantage points for addressing how safety and security are converging: the conceptual approach, the technical and methodological approach, and the management and practice approach. We then go on to show that, as professional areas, safety and security have developed in different ways and supported by quite separate scientific and technological fields. Finally, we present the organization of the book.
... Consequently, there are well-established institutional/management strategies, collaborations, and practices associated with preventing incidents and accidents. Maintaining the efficacy of these approaches is viewed as important for protecting hazardous technologies, as they are based on previous incidents and include the dynamic yet fragile organizational web of safety defenses [24]. From the 1980s, supported by an increased understanding of how and why accidents happen, increased attention was paid to how accidents and disasters are caused by societal developments [6]. ...
... Again, the personal engagement dimension associated with safety culture is a critical element in safety. From high reliability organizations (HRO) research (LaPorte and Consolini 1991;LaPorte, 1996;Schulman 1993;Roe and Schulman, 2008;Hopkins, 2009;MacRae, 2014) it is possible to give a clear description of what actually constitutes at least one type of safety culture. This is one associated with a set of organizations with excellent records in managing hazardous technical systemsnuclear power plants, commercial aviation (including air traffic control) and other critical infrastructures including high-voltage electrical grids and large municipal water supply systemsto high levels of reliability and safety. ...
Article
Full-text available
This essay argues that: (1.) The concepts of both “safety” and “safety culture” are under-developed in organizational analysis. This has led to ambiguity and confusion in our understanding of the causal connection of both to specific elements of organizational structure. (2.) There is more complexity in the link between structure and safety culture as features of organization than might be supposed. The actual content of structural elements such as roles and rules, functional lines and limits of authority, accountability and communication – can themselves require closely supporting cultural norms of acceptance to actually function as formally described. Otherwise a formal organization chart can be a highly misleading picture, as they often are, of actual transactions occurring within a functioning organization. (3.) But the relationship between structure and safety culture can be different in the different phases of (1) the initial change of cultural or sub-culture features that undermine safety, (2) safety culture development and finally, (3) the challenge of the continued maintenance of a safety culture over time in an organization. (4.) Both specific safety management structures and a reinforcing safety culture are essential within an organization to reach across the scope of activities and time frames necessary for reliable safety performance. The implications of these points are explored for both future safety research and regulatory practice concerning organizational structure and safety culture and, ultimately, to connecting both to the improvement of safety performance.
... A common language and set of shared ideas and agreed objectives is essential when attempting to coordinate any sort of regulatory activity-and this has been achieved over time in many other industries. 15 Health regulators have been urged to develop a shared "theory of regulation" that encompasses a common purpose, common objectives, and a shared understanding of the association between regulation and improvement. 12 ...
Article
Healthcare relies on a variety of regulatory activities to manage risks to the public and to drive improvement. But the regulation of patient safety in healthcare, and in the NHS in particular, is “bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies.” (Berwick 2013). Regulatory activities touch every single aspect of care delivery and place considerable demands on professionals and organisations alike, in the form of inspections, certification, accreditation, revalidation, and compliance reporting. We argue that the safety regulatory system, as seen from the perspective of provider organisations, is much larger and more complex than usually supposed. Individual regulators might achieve valuable impact, but the system as a whole is unnecessarily burdensome, produces multiple unintended consequences, and, most importantly, fragments and dilutes regulatory impact. We discuss the nature of these problems and set out a series of practical proposals for tackling these critical challenges.
... 9 Some industry-based safety culture descriptions have been offered in: "Traits of a Healthy Nuclear Safety Culture" (U.S. Institute of Nuclear Power Operators, 2012); "Safety Culture" (U.K. Health and Safety Executive, 2019) and "Introduction to Process Safety Culture" (U.S. Center for Chemical Process Safety, 2019). solini 1991; LaPorte, 1996;Schulman 1993;Roe and Schulman, 2008;Hopkins, 2009;MacRae, 2014) it is possible to give a clear description of what actually constitutes at least one type of safety culture. This is one associated with a set of organizations with excellent records in managing hazardous technical systems --nuclear power plants, commercial aviation (including air traffic control) and other critical infrastructures including high-voltage electrical grids and large municipal water supply systems --to high levels of reliability and safety. ...
Article
Full-text available
This essay argues that: (1.) The concepts of both “safety” and “safety culture” are under-developed in organizational analysis. This has led to ambiguity and confusion in our understanding of the causal connection of both to specific elements of organizational structure. (2.) There is more complexity in the link between structure and safety culture as features of organization than might be supposed. The actual content of structural elements such as roles and rules, functional lines and limits of authority, accountability and communication – can themselves require closely supporting cultural norms of acceptance to actually function as formally described. Otherwise a formal organization chart can be a highly misleading picture, as they often are, of actual transactions occurring within a functioning organization. (3.) But the relationship between structure and safety culture can be different in the different phases of (1) the initial change of cultural or sub-culture features that undermine safety, (2) safety culture development and finally, (3) the challenge of the continued maintenance of a safety culture over time in an organization. (4.) Both specific safety management structures and a reinforcing safety culture are essential within an organization to reach across the scope of activities and time frames necessary for reliable safety performance. The implications of these points are explored for both future safety research and regulatory practice concerning organizational structure and safety culture and, ultimately, to connecting both to the improvement of safety performance.
... Psychology or sociology of organisation, science and technology studies and management research have developed concepts such as organisational reliability or collective mindfulness, incubation or normalisation of deviance and migration/drift, as well as notions of learning and (safety) cultures (e.g. Rasmussen, 1997, Snook, 2000, Weick, Sutcliffe, 2007, Hopkins, 2009, Downer, 2011, Macrae, 2014. When developing these ideas, concepts and themes based on a range of case studies, actors such as operators, but also managers and engineers, have been the primary subjects of these research traditions. ...
Article
The aim of this article is to explore the contribution of powerful actors of organisations to the construction of safety in high-risk systems. Accident investigation reports and empirical research of daily operations of high-risk systems have targeted organisational issues since the 1990s. However, although one observes in safety research a group of disciplines contributing to advance knowledge in this direction, such as sociology, management or political science, nothing much is available in the field of strategy. Yet, the argument of this article is that it is useful to also frame the study of safety and accident from a strategic angle of analysis. In a first section, safety research is briefly introduced, then in a second section the field of strategy is explored, including studies of strategic failures. Reasons for the relative absence of an interest in the relation between strategy and safety are advanced and argued. It is believed that there is a need to advance our knowledge on the topic of safety from the point of view of the psychology and sociology of executives and top managers, particularly in relation to strategy. In a last section, illustrations of how strategic decision making matters tremendously for our understanding of safety are introduced and discussed. Outlines of a research agenda are described. Overall, this article proposes to reformulate the notion of ‘latent causes’ of disasters as various degrees of strategic breakdown.
... Ethnography may also offer insights on the wider organisational and cultural dynamics that may explain why accidents or 'close calls' are welcomed as a learning opportunity in some contexts and ignored or normalised in others. 29 Systems engineering focuses on how to design and manage complex systems over their lifecycles. Adopting 'systems thinking' principles 30 and approaches from human factors analysis, 31 it seeks to ensure that all relevant aspects (social and technical) of a complex process or system are considered and integrated into a whole. ...
Article
Full-text available
Introduction Suboptimal electronic fetal heart rate monitoring (EFM) in labour using cardiotocography (CTG) has been identified as one of the most common causes of avoidable harm in maternity care. Training staff is a frequently proposed solution to reduce harm. However, current approaches to training are heterogeneous in content and format, making it difficult to assess effectiveness. Technological solutions, such as digital decision support, have not yet demonstrated improved outcomes. Effective improvement strategies require in-depth understanding of the technical and social mechanisms underpinning the EFM process. The aim of this study is to advance current knowledge of the types of errors, hazards and failure modes in the process of classifying, interpreting and responding to CTG traces. This study is part of a broader research programme aimed at developing and testing an intervention to improve intrapartum EFM. Methods and analysis The study is organised into two workstreams. First, we will conduct observations and interviews in three UK maternity units to gain an in-depth understanding of how intrapartum EFM is performed in routine clinical practice. Data analysis will combine the insights of an ethnographic approach (focused on the social norms and interactions, values and meanings that appear to be linked with the process of EFM) with a systems thinking approach (focused on modelling processes, actors and their interactions). Second, we will use risk analysis techniques to develop a framework of the errors, hazards and failure modes that affect intrapartum EFM. Ethics and dissemination This study has been approved by the West Midlands—South Birmingham Research Ethics Committee, reference number: 18/WM/0292. Dissemination will take the form of academic articles in peer-reviewed journals and conferences, along with tailored communication with various stakeholders in maternity care.
Article
Objectives System-wide learning for patient safety is a core challenge for the health care sector, despite the prevalence of localised reporting and learning approaches. There is growing interest in how health care services could emulate other safety-critical sectors with the introduction of specialist safety investigation agencies to inform sector-wide safety. This paper reports on a study of the introduction and early operation of one such agency in the English health and care system. Methods This was a qualitative interview study carried out between 2019 and 2021 and co-designed through a partnership between University researchers and the Executive Team from the Healthcare Safety Investigation Branch (HSIB) to explore the organisational development of this ‘first of type’ organisation. The study involved interviews with 33 internal and external stakeholders and documentary analysis of HSIB reports. Results The study findings highlight the organisational competencies and developmental challenges experienced in the early years of HSIB operations focusing on (i) independence and fit within the wider system; (ii) the selection and scope of investigations; (iii) the methodology and investigation approach; and (iv) the skill and competencies of investigators. Conclusions This study offers practical learning to health care decision-makers about the importance of securing independence and integration, about the production of system-wide learning, the standardisation of robust methodologies and the support for a multidisciplinary specialist workforce.
Article
Autonomous and intelligent systems (AIS) are being developed and deployed across a wide range of sectors and encompass a variety of technologies designed to engage in different forms of independent reasoning and self‐directed behavior. These technologies may bring considerable benefits to society but also pose a range of risk management challenges, particularly when deployed in safety‐critical sectors where complex interactions between human, social, and technical processes underpin safety and resilience. Healthcare is one safety‐critical sector at the forefront of efforts to develop and deploy intelligent technologies, such as through artificial intelligence (AI) systems intended to automate key aspects of healthcare tasks such as reading medical images to identify signs of pathology. This article develops a qualitative analysis of the sociotechnical sources of risk and resilience associated with the development, deployment, and use of AI in healthcare, drawing on 40 in‐depth interviews with participants involved in the development, management, and regulation of AI. Qualitative template analysis is used to examine sociotechnical sources of risk and resilience, drawing on and elaborating Macrae's (2022, Risk Analysis , 42 (9), 1999–2025) SOTEC framework that integrates structural, organizational, technological, epistemic, and cultural sources of risk in AIS. This analysis explores an array of sociotechnical sources of risk associated with the development, deployment, and use of AI in healthcare and identifies an array of sociotechnical patterns of resilience that may counter those risks. In doing so, the SOTEC framework is elaborated and translated to define key sources of both risk and resilience in AIS.
Article
Full-text available
Barry Turner’s 1978 Man-made Disasters and Charles Perrow’s 1984 Normal Accidents were seminal books but a detailed comparison has yet to be undertaken. Doing so is important to establish content and priority of key ideas underpinning contemporary safety science. Turner’s research found socio-technical and systemic patterns that meant that major organisational disasters could be foreseen and were preventable. Perrow’s macro-structuralist industry focus was on technologically deterministic but unpredictable and unpreventable “system” accidents, particularly rare catastrophes. Andrew Hopkins and Nick Pidgeon respectively suggested that some prominent writers who wrote after Turner may not have been aware of, or did not properly acknowledge, Turner’s work. Using a methodology involving systematic reading and historical, biographical and thematic theory analysis, a detailed review of Turner’s and Perrow’s backgrounds and publications sheds new light on Turner’s priority and accomplishment, highlighting substantial similarities as well as clear differences. Normal Accidents did not cite Turner in 1984 or when republished with major additions in 1999. Turner became better known after a 1997 second edition of Man-made Disasters but under-acknowledgment issues by Perrow and others continued. Ethical citation and potential reasons for under-acknowledgment are discussed together with lessons applicable more broadly. It is concluded that Turner’s foundational importance for safety science should be better recognised.
Article
The COVID‐19 pandemic has challenged and changed organisations. While the pandemic has brought opportunities for business in some sectors, such as information and communication, and for people who enjoy the flexibility they gain from home‐based or hybrid work arrangements, the realisation of benefits for individuals and organisations is uncertain over longer time periods and distributed unevenly across the workforce. Thus, the pandemic situation has been a trigger, albeit an unwelcome one, for revising our theorising about organisational risk. We build on the articles within our special section and develop a perspective on how to continue the development of new theoretical insights. First, we examine how existing theories can be extended to encompass organisational risk. We focus on theories of organisational culture to do so. Second, we discuss ways that existing theories can be repurposed to address important challenges. We illustrate our points using paradoxical leadership theory and theories of creativity. Third, we reflect on ways to develop new theorising by exploring multilevel modelling and the microfoundations of organisational risk. Fourth, we reflect on methods. In doing so, we pave the way for future studies that will enrich our understanding of organisational risk and contribute to preparations for future crises.
Article
Full-text available
When a perceptual order is turned into a conceptual order a disjunction between continuity and discontinuity is created. Sensemaking to manage this disjunction often consists of attributions of typicality formed intuitively or through deliberation. The details lost during this process can lead to further breakdowns. This process of “arrested sensemaking” is illustrated with a disaster at sea when a 790-foot container ship, the El Faro, sailed into the eye of a category 3 hurricane and capsized. All 33 crew members perished. The prevailing sense was that the rough seas were a “typical” storm, arresting sensemaking in the face of a looming disaster.
Article
Full-text available
Objective: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward. Methods: Narrative literature review. Results: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety. Conclusions: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.
Book
Full-text available
Inside Hazardous Technological Systems explores the applications, opportunities and challenges of applying qualitative methodologies to critical questions of organizational research and practice in the field of safety science. This book provides a broad exploration of the practices and methods of doing research, conducting fieldwork, and developing theory of hazardous technological systems, drawing on a range of different approaches and traditions. These span from critical accounts of applying interpretive and social research methods in organisational settings, to explorations of the opportunities and importance of integrating qualitative and quantitative methods, to practical reflections on the challenges associated with negotiating access to research sites and building theory from data. Recognizing methodological issues that cut across the fields of safety, risk and accident analysis, it provides academics, researchers, students, and professionals with a broad-ranging and expert guide to research strategies and histories, considerations of particular research methods, as well as reflections on the challenges and opportunities for integrating and combining methods and looking to new empirical domains.
Article
Full-text available
This essay argues for the importance of error as an organizing concept in the management of hazardous technical systems to high levels of reliability and safety. The concept of “error” has been essential to the development of high reliability organizations (HROs). As practiced in HROs, error management has also been an important strategy for the management of uncertainty. “Uncertainty” has been conceived by some analysts as a condition that can convey little or no reliable information about its own boundary conditions or its specific threat to the operation of complex systems. The argument here is that uncertainty is differentiated and specified in HROs and provides important information in relation to error. Uncertainty does not, in the special context of HROs, end the possibility and practice of reliable management. In fact, error in HROs can be a starting point for the further analysis of ways in which uncertainty itself can be managed reliably. But the argument offered here does not mean that uncertainty does not challenge reliability in other settings. The COVID‐19 pandemic is offered as an example of how uncertainties may invalidate even the application of "reliability" as a performance standard in certain domains of management and policy.
Article
Full-text available
Background: Reducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of 'what good looks like'. Objective: We aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement. Methods: We conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group. Results: We identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification. Conclusions: This large qualitative study has enabled the generation of a new plain language framework-For Us-that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units.
Article
A commemoration is an invitation to go beyond the thing being commemorated. Such an invitation to surpass becomes more compelling when the thing commemorated is summarized and updated and the surpassing more vividly illustrated. This essay does the former by means of selective references to both editions of the “Social Psychology of Organizing” (1969, 1979). The essay describes an evolving vocabulary intended to focus on meaning and collective action. The three associated studies in this special section extend that vocabulary.
ResearchGate has not been able to resolve any references for this publication.