SCTA in Reverse (Part 3): Reflections, Challenges, and the Emerging TABIE Toolbox
We can finally close the gap between proactive SCTA and reactive investigation, using the same analytical framework to both prevent disasters and understand them when prevention fails.
SCTA in Reverse (Part 2): Dissecting the Herald of Free Enterprise Disaster with TABIE Tools
This is part 2 of our “SCTA in Reverse” series, diving deep into the Herald of Free Enterprise disaster through the lens of TABIE (Task Analysis Based Incident Evaluation).
SCTA in Reverse (Part 1): Learning from the Herald of Free Enterprise Disaster
On March 6, 1987, the Herald of Free Enterprise capsized in just 4 minutes after leaving Zeebrugge, killing 193 people. The immediate cause was clear – sailing with bow doors open. But the real lessons lie deeper.
Kegworth Revisited: A Case for Systemic Thinking
On 8 January 1989, British Midland Flight 92 crashed just short of East Midlands Airport, killing 47 people. But the Kegworth disaster wasn’t just about a mistaken decision, it was the result of multiple system failures.
The 2005 Stockwell Shooting: A lethal stew whose ingredients had been long in the cooking
Using the 2005 Stockwell shooting as a case study, this blog demonstrates how major incidents rarely result from single failures, but rather from the alignment of multiple systemic weaknesses across five stages.
Using SEIPS to Understand and Improve Patient Safety
Lydea’s latest blog explores how the Systems Engineering Initiative for Patient Safety (SEIPS) framework help move human error beyond individual actions to systemic factors that contribute to such incidents.
The blog identifies key vulnerabilities and explores potential opportunities for improvement to enhance patient safety.
Beyond the Basic HSE PIF list: Reflections on types of Performance Influencing Factors
We often rely on standard HSE checklists for identifying Performance Influencing Factors, but there’s so much more to consider.
Revisiting the Swimlane Method: A Healthcare Case Study to Improve Patient Safety
Lydea’s latest blog explores how Swimlane could be applied in the healthcare industry. By mapping out the sequence of events, the tool helped uncover opportunities to improve processes and enhance safety.
Near Miss Management: Formative ideas for a book chapter
I’ve been lucky enough to be invited to contribute a chapter in a book about Near Miss Management. I’ll mainly be discussing the application of Human Factors Safety Critical Task Analysis (SCTA) for investigating near misses for Process Safety related concerns.
I wanted to share these early ideas and request feedback from you, the reader.
Incident Investigation: Swimlanes & Sequentially Timed Events Plotting (STEP)
Lydea’s latest blog uncovers Swimlane diagrams as a powerful tool for incident investigation. Featuring a detailed case study on the AB Specialty Silicones explosion in 2019, learn how this tool can map out complex processes, identify latent conditions and active failures, and enhance your understanding of critical events.
