Digital Engineering Library

Systems as Imagined v Systems in Practice The recent NSW Supreme Court decision,  Attorney General of New South Wales v Tho Services Limited (in liquidation) (ACN 000 263 678) [2016] NSWCCA 221  is another in a long line of decisions that highlight the disconnect between safety management systems as they are documented, and what occurs in practice. Documented safety processes are important.  They provide guidance on how safety is managed and evidence that an organisation is meeting its obligations.  However, where an accident reveals long-term, systemic non-compliance with obvious safety expectations documented safety processes do not provide a defence, often they do not provide mitigation, and in cases such as this they are an aggravating circumstance.  As the Court noted: The vast range of induction and supervising protocols adopted by the respondent or in force at its premises serves not to relieve the respondent of its responsibility for safety but on...

A Little Challenge For Experienced Safety Professionals Only Calling on all experienced Safety Professionals with a sharp mind and a discerning eye…..We all know how important it is to wear as much PPE as possible when working on a construction site – it wont really stop many serious injuries but it does allow the maintenance of control, mean we can pad out inductions, gives a reason to yell at people and creates the illusion of a safe workplace. Could you please tell me one critical thing that is missing from this sign spotted recently at the entrance to a construction site and what is that telling you about the culture and the approach to safety on this site?: “Wear 4” – sounds like the beginning of a line from a Shakespeare play……. that line is a clue to the answer to the question above and no it isn’t gloves, hearing protection or a dagger!!! UPDATE: Well, after a few thousand views nobody has yet solved the puzzle – sometimes the answers can be lost in all the noise, di...

The Mountain Has Been Climbed. Now What? by Phil La Duke, first published here:  https://philladuke.wordpress.com/2016/10/17/the-mountain-has-been-climbed-now-what/ You’re corporate incident rate is so low that you are the envy of your industry, so where do you go from here? Despite the ever increasing death traps that we call workplaces, it’s a valid question that some fortunate companies have to deal with.  You could chase that last delta and spend more and more money achieving less and less meaningful results, or you could shift your focus away from body counts to levels of risk. Am Managing Indicators Or Risk? I go on a fair amount of pointless sales calls where safety managers beam with pride over their sterling safety metrics and puff up their chests and brag about this supposed innovative practice or another. Silently I ask myself is things are running so well, why am I here.  If you don’t need help, why in the hell are you wasting my time?  But they ...

Promoting Dumb, Anxiety and Harm in the Name of Good The by-products of not being educated in the challenges of ethics and ideology in safety training are many ( http://www.safetyrisk.net/isnt-it-time-we-reformed-the-whs-curriculum/ ). The first by-product is the development of policy by naivety and ignorance. This is where we find language that hides a dehumanizing trajectory in the name of good. Someone gets some admirable idea such as they don’t want anyone harmed then turns that single idea into a policy without any thought of long term consequences or cultural outcomes. Then out comes some slick marketing campaign based upon a short term focus, masked in the name of good. Then it doesn’t take long and soon people discover that the by-products of that campaign create toxic outcomes as the hidden ideology becomes known, especially to those who generate the campaign. Then with so much sunk cost, the campaign deepens under the stress of cognitive dissonance. We see this in the Du...

Incident Investigation and the Limits of Risk Imagination ‘Everything you can imagine is real’ – Pablo Picasso I often get asked to investigate incidents from a cultural perspective. Whilst, most investigations focus on physical detail and sequence, I explore cultural and psychological causes. This is undertaken within the framework that incident investigations are about ‘fact finding’ not ‘fault finding’. Whilst all of the physical elements of investigation are most necessary I take a particular focus on what cultural and socialpsychological factors contributed to a physical outcome. I recently supported an organisation investigating their Lost Time Injuries (LTIs) over a 10 year period and determined that 90% of all their LTIs were primarily caused by psychosocial and culture factors. Their investigations has attributed causation to 90% physical factors. Most of the key elements of what makes up culture are hidden. Culture is detected through physical indicators such as; sy...

I was doing some research on incident investigation tools today and recalled this VERY popular post from last year. The SCM nicely allows us to take our pick of endless causes and to assign blame to not only the worker but management, the system and objects as well – no wonder it and ICAMembert are so popular: A Critique of Pure Reason –  (With Apologies to Immanuel Kant) There is not a week goes by without someone suggesting I should read James Reason or that I haven’t read James Reason. I am also advised that I don’t read James Reason properly because somehow all worldviews must be in agreement, particularly in safety. In the short history of safety, the works of Reason particularly, the Swiss Cheese metaphor (causation theory) and Human Error theory have become attributed as fact. Should one disagree with Reason’s theories one obviously can’t read or hasn’t read Reason’s work properly. It is interesting to note the way that Reason is used to invoke reductionist ...

Signs On a Church Refurbishment Site Spotted these signs on the fence of a Church refurbishment project today. When I saw the irony (is that what you would call it?), I laughed until I stopped……