THE WEEKLY
REFLEKTION
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The Weekly Reflektion 36/2023
There are many indicators that could be used to determine whether you have safe and efficient operations. If you know what you are looking for, you can build up a pretty good picture of how you are doing. However, if you cannot distinguish the relevant indicators, you may not have the right impression. When the indicators you are using confirm what […]
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The Weekly Reflektion 18/2023
Management visits to worksites are important for both conveying messages and receiving information and are typically included in the company Key Performance Indicators (KPIs). The intention is encouraging management to move away from their back-to-back meetings and ‘little time to reflect’ working day and go out and see how the workers are surviving at the sharp end. What signals […]
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The Weekly Reflektion 50/2022
The investigations into major accidents often note the signals before the accident that indicated some things were not right. The disregard for safety precautions, the breaches of the control of work procedure, recurring incidents, concerns from the staff. Sometimes the signals are strong, for example a dropped object from 20 meters. Sometimes the information may […]
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The Weekly Reflektion 41/2021
As systems become more complicated and control systems more sophisticated, Human-Machine Interface (HMI) is becoming increasingly important. Do you have good control of HMI in your operation? China Airlines flight 140, flying from Taiwan, was making its approach to Nagoya Airport in Japan on 26th April 1994. The first officer was flying the aircraft and he was experiencing problems pushing the nose down to […]
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The Weekly Reflektion 39/2021
We often talk about the importance of culture in influencing the behaviours of people in an organisation. But do we really understand how the culture has an affect and what aspects of the culture are actually influencing people? Do you understand how culture influences people in your organization? One of our Reflektions in April 2019 […]
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Reflektion – Equinor experience transfer final
We normally send out our Weekly Reflektion on Sunday morning and hopefully all our subscribers are happy with this routine. We decided to send out this extraordinary Reflektion today as it relates to one of the concerns we have on Major Accident Prevention in the Norwegian Petroleum Industry, complacency. The Reflektion is a reaction to […]
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The Weekly Reflektion 29/2021
What is the worst Major Accident we have come across? What criteria should we use to judge the many Major Accidents that we have studied? The consequences in the terms of loss of life, impact on the environment or financial loss? In our view it is more appropriate to judge based on the failure of […]
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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 13/2021
Do you notice an area for improvement, make a note to do something about it, but then forget? Don’t put off taking action. This week’s Reflektion concerns an incident in the Gulf of Mexico where a hazard was recognised, but immediate mitigating actions proved insufficient. A hardhat, a clipboard, and an open grating On a […]
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The Weekly Reflektion 09/2021
The standards we use do originate somewhere. Do not dismiss them without knowing where they come from and what they were intended to do. Could an accident with 21 fatalities caused by a lack of competence and failure to recognize signals happen in your operation? On January 15th, 1919, a tank 15m tall, 27m in […]
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The Weekly Reflektion Week 27 / 2020
The ‘elephant in the room’ is often used to describe an issue that everyone knows is the most important issue for the people in an organization, however it is not the issue that is being discussed. Peter Sandman, an advocate of effective risk communication, uses the example of how Exxon communicated their environmental policy following […]
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The Weekly Reflektion Week 25 / 2020
Reflekt was started in October 2017 and our focus was to use the insight from investigations into Major Accidents to learn and hence prevent future Major Accidents. We also believed that these insights would provide learning to improve performance in other areas. Reflekt has organized seminars and lunch and learns, facilitated workshops, and carried out […]
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The Weekly Reflektion Week 08 / 2020
This week’s Reflektion considers the Yorkshire dam disasters of 1852 and 1864. Do you know where the requirements in the standards you use originated? Are you vigilant for signals that the standards could be improved? In the 19th century in Yorkshire, dams were being built to guarantee a supply of water for power for the […]
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