THE WEEKLY
REFLEKTION
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The Weekly Reflektion 49/2024
Accidents and incidents are often attributed to human error and in many cases, this may be the case. Why people did what they did, and why they considered it rational in the situation and circumstances they were in, needs to be understood before we play the human error card. Sometimes a more detailed investigation discovers that it was not human error at all. […]
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The Weekly Reflektion 18/2024
In many industries we are relient on computers, PC’s andautomated systems for a safe and efficient operation. We are then dependent on the way people interact with these and how the human machine interfaces (HMI) are set up. Are your human-machine interfaces designed to help or hinder? Air Inter Flight 148 was a scheduled flight from Lyon […]
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The Weekly Reflektion 10/2024
In all operations there are some tasks that are more important than others since they can have serious consequences if mistakes are made. We need to differentiate between critical and non-critical tasks and have processes in place to ensure critical tasks are carried out properly. MV Golden Ray after capsize In your operation are you conscious of what is critical and non-critical? The MV Golden […]
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The Weekly Reflektion 52/2023
Many companies are making the transition from ‘Human Error’ to ‘Human Performance’ in the way they investigate incidents and accidents and how they improve their performance. The ‘Human Error’ approach was based on the identification of what went wrong, who made the mistakes and led to actions to correct mistakes to prevent recurrence. The investigations most often did not get to the root of […]
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The Weekly Reflektion 21/2022
A simple ‘human error’ can lead to fatal consequences. Sometimes a simple solution could have prevented the human making that error and the pain and misery of lost loved ones could have been avoided. Do you design your systems to prevent the inevitable mistakes that people will eventually make? We would like to invite you to […]
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The Weekly Reflektion 13/2022
Human error plays a part in most accidents. Do your investigations stop there? Injury to boy’s neck after accident on the ski lift. Photo: Private Do you consider ‘inherently safer design’ in your investigations? In February this year, an 11-year-old boy was on downhill skis for the first time at a Norwegian ski resort, when […]
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The Heimdal Incident
Failure to carry out a proper investigation of any incident, especially a serious incident, is a barrier to the learning from the incident. When reading some investigation reports and presentations, it is not surprising that learning from incidentsis a still a challenge. When you carry out investigations, do you really get to the bottom of what happened, how it happened, and why […]
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The Weekly Reflektion 25/2021
The saying ‘beware of Greeks bearing gifts’ is normally used to refer to an act of charity that masks a hidden destructive or hostile agenda. The saying comes from Greek mythology andthe Trojan War, in which the Greeks, led by Agamemnon, attempted to rescue Helen, who had been taken to Troy after falling in love […]
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The Weekly Reflektion Week 42 / 2020
Does creating a scapegoat bring the team together? This week’s Reflektion concerns the clash between a blame culture, and a learning culture. Does getting rid of the people who make mistakes improve overall team performance? A few years ago, I was responsible for drilling operations on an offshore production platform. During a well operation the drilling supervisor proposed […]
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The Weekly Reflektion Week 23 / 2020
This week’s Reflektion concerns a train crash in 1988 in Paris where a chain of events caused an incoming train to collide with a stationary outgoing train. Driver error was identified as the cause. Given today’s prevailing view that human error is a symptom and not a cause, we will revisit the accident. People make […]
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The Weekly Reflektion Week 51 / 2019
This week’s Reflektion is a follow up on the Reflektions in week 49 and week 50 and concerns the process of changing of our mental models. Learning is not the just the accumulation of knowledge. Learning is the application of new knowledge and new experience to a desired end. Learning requires a change in the […]
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The Weekly Reflektion Week 50 / 2019
This week’s Reflektion is a follow up on week 49 Reflektion on human error and considers the concept of mental models. Do you have ‘human error’ down as one of the main causes for accidents and incidents? What mental model did the person(s) involved in the accident or incident have and how did this influence […]
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The Weekly Reflektion Week 49 / 2019
This week’s Reflektion is inspired by a presentation on Causal Learning that we recently attended and some reflections around the concept of ‘human error’. Do you have ‘human error’ down as one of the main causes for accidents and incidents? Maybe you should think about the cause of human error rather than human error as […]
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