When faced with a ’human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable pe...

What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and...

How is it possible that the desire for a perfectly safe world with perfectly safe workplaces helps generate the opposite? Safety Theater shows how our desire for perfection drives compliance clutter, inauthentic relationships with work-as-done, and new kinds of accidents. Written by the leading global voice on safety innovation today, Safety Theater takes us back to the Enlightenment and its aspiration toward a perfectible world through rationality and science, and explai...

Being a Crisis Chaplain delivers the essential elements of crisis chaplaincy, outlining the process of responding to crises with clarity and compassion. Drawing from real‑world experiences and research, this is a concise but comprehensive toolkit for navigating the delicate aftermath of crises.Chapters explore ways to triage emotional, cognitive, and spiritual needs, from the raw shock and grief to complex feelings of guilt and helplessness. With practical guidance for rec...

In the world of work, accountability can often translate into punishment. This book explores trust, learning, and accountability in the aftermath of incidents. Fully updated, the fourth edition of Restorative Just Culture covers restorative justice, challenging conventional notions of blame and retribution to create a “just culture” in the workplace.Whether you’re grappling with the fallout of an incident or seeking to foster a culture of trust and compassion, this book of...

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. At the same time, progress on safety has slowed to a crawl. Many incident- and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities...

This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide ...

In the realm of safety management, this book embarks on a profound exploration of how the political economy was reshaped in the last two decades. Much like privatization, deregulation, and financialization altered the economic landscape, this narrative unveils how safety management has been affected by the intertwined dynamics of asset underinvestment, privatization, self-regulation, workplace flexibilization, and market-driven policies.This book, the second installment of a though...

A restorative just culture has become a core aspiration for many organizations in healthcare and elsewhere. Whereas ‘just culture’ is the topic of some residual conceptual debate (e.g. retributive policies organized around rules,violations and consequences are ‘sold’ as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what t...

In this book, Sidney Dekker sets out to identify the market mechanisms that explain how less government paradoxically leads to greater compliance burdens. This book gives shape and substance to a suspicion that has become widespread among workers in almost every industry: we have to follow more rules than ever—and still, things can go spectacularly wrong.Much has been privatized and deregulated, giving us what is sometimes known as ‘new public management,’ driven by neoliberal, mar...

Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors

Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reve...