I’ve recently published an article on the application of systems thinking concepts in accident analysis. The article is published in Safety Science available via ScienceDirect. The paper includes a discussion on the Bellevue fire in Western Australia.
Anyone interested in the article can contact me via y.goh @ curtin.edu.au (remove the spaces adjacent to “@”)
James Reason (Managing the Risks of Organizational Accidents) argues that an informed culture is a safety culture. Reason feels that an informed culture is one where the management is fully informed on the system that they are managing. However is it possible for managers to be fully informed of the hazards and status of the system?
One basic ingredient for this to be possible is for the organisations to have a well-designed safety knowledge management system that captures safety-related information, and codify them so that they can be retrieved when necessary. Once retrieved it is then important for these past information to be adapted by the users for application… this process can be modelled based on the case-based reasoning process, which basically emulate how humans recall past experiences and reuse them in new situations.
I did some work in this area, but only at preliminary prototype stage. We developed a conceptual framework that enables incident cases and past risk assessment to be reused during new risk assessment. Hopefully there will be opportunities to implement them in actual situations.
For those interested see this book for an introduction to case-based reasoning: Applying Case-Based Reasoning: Techniques for Enterprise Systems (The Morgan Kaufmann Series in Artificial Intelligence)
Was reading Stephen Covey’s “The Leader in Me: How Schools and Parents Around the World Are Inspiring Greatness, One Child At a Time”, and he was describing how a school succeeded in implementing a significant change in its culture, systems and processes. The school started with pilot groups to demonstrate how the new approach is effective and useful. With the initial successes the rest of the school became more willing to change…
The same approach applies to changes to safety culture… we cannot change an organisation’s safety culture overnight, even if we can, the change will not be sustainable… we are talking about “profound cultural change” here. It is best to start off with small pilot projects that aims to change the culture. The design of the pilot projects and the selection of participants are extremely important. These projects have to be a convincing “hit” with the organisation. The projects has to be credible and successful so that it serves as a showcase that the new culture or approach to safety is beneficial at individual, group and organisation levels…
Straits Times reported that the Singapore Flyer (a larger version of the London Eye) which stopped about 3 weeks ago, had similar incidents before. The previous incidents were relatively minor as compare to the Dec 23 08 incident, where 173 passengers were stuck in the wheel for more than 6 hours.
Incidents like this would have similar organisational factors and cultural issues as in Columbia Space Shuttle incident (see my last post). Being one of the major tourist attractions of Singapore and the fact that there are lots of media and public attention on the flyer, it is not surprising that the organisation is under pressure to push the flyer to function as plan… I hope the on-going inquiry will look into these organisational and cultural issues.
NASA just released a report titled, “Columbia Crew Survival Investigation Report”. The final report is focused on the technical issues involved in the Columbia space shuttle accident in 2003. The report can be downloaded from http://www.nasa.gov/news/reports/index.html.
To me, the 2003 investigation report by the Columbia Accident Investigation Board is more interesting… the report can be downloaded from the same website above. The 2003 report covered organisational factors that contributed to the accident. As in most major incident investigation reports, safety culture was highlighted as a key contributor. The investigation board also highlighted the relationship with the Challenger accident. Very interesting insights. Worth reading…
