THE WEEKLY
REFLEKTION
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The Weekly Reflektion 27/2023
Investigations into incidents and accidents are essential to find direct and underlying causes and to initiate measures to prevent recurrence and improve performance. The failure of processes and systems is demonstrated by the fact that an incident has occurred, and the incident and its circumstances give pointers on where to look for improvements. Just as […]
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The Weekly Reflektion 03/2023
When organisations are busy, undermanned, and have other important tasks to perform, investigations are often not prioritised. Sometimes the objective is carry out an investigation rather than getting to the root of the problem. After a potentially fatal accident, do you hope that statistics are on your side, and do nothing? In February 2022, an […]
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The Weekly Reflektion 45/2022
Language and communication have been major factors in the evolution of humans. The ability to learn and adapt to changing environments gave homo sapiens a great advantage despite obvious deficiencies in strength and speed compared with other predators and prey. Before the advent of writing systems communication was verbal, and it is likely that the […]
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The Weekly Reflektion 37/2022
Acronyms are abbreviations formed from the initial letters of the words in the expression being abbreviated. Some acronyms become so well established that they replace the original name or expression, e.g., NASA, IOU, SNAFU. Often the acronym becomes memorable and conveys a distinct understanding. The acronyms we are using today are WYLFIWYF and WYFIWYF. Are you aware that the mandate for an investigation and […]
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The Weekly Reflektion 19/2022
Repeated incidents show that we are often not effective at learning lessons and preventing recurrence. People can be seriously injured or die from this failure. Learning lessons demands organisational stamina to follow the process to the end. How is the stamina in your organisation? Several of our Reflektions recently have addressed the quality of investigations […]
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The Weekly Reflektion 17/2022
Failure of leadership and supervision is often noted as a factor in incidents and accidents. Unfortunately, this is often an observation made by the investigation team and not a cause that has been identified through an assessment of why the leadership/supervision failed. Are your expectations to operational leaders/supervisors clear? One of the perceived advantages of the […]
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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 Weekly Reflektion Week 21/2021
Once an organisation establishes a mindset it can be difficult to change and sometimes it takes a serious incident to realise the mindset was not good. Do you let your mindset blind you to the causes of your next disaster? I was just sitting down at my desk to write a Reflektion and as I […]
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The Weekly Reflektion Week 10/2021
Thank you to everyone that attended the Reflekt Lunch and Learn on Resilience on 18th February.One of the examples we used was the blowout on the Snorre A platform in 2004 where a subsurface hydrocarbon leak from a well compromised the suction anchors for the tension legs and threatened the platform with fire and explosion. […]
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The Weekly Reflektion Week 35 / 2020
While working on an assignment connected to Major Accident prevention, I needed to refer to the report from the Cullen Inquiry into Piper Alpha. The particular issue was related to the authority an investigation leader has to extend the investigation mandate in order to cover issues that may not have been considered in the original […]
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The Weekly Reflektion Week 04 / 2020
Reflekt was started in October 2017 and since then we have produced 115 Reflektions that we hope have been interesting reading and perhaps provided useful learning. Reflekt has also organised five seminars on learning from Major Accidents. Our belief that the unique insights from the investigations into Major Accidents can be used both to prevent […]
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