Are We Collecting Data, or Are We Learning?
Organisations are rarely short of information. Incident reports, near-miss records, audits, KPIs and procedure reviews can all provide valuable insight. But data only becomes useful when it helps us understand how work is really done, why performance varies, and what needs to change.
The Railway Men of Bhopal: How Recovery Shaped the Impact of Disaster
Inspired by The Railway Men, this blog uses the Accident Sequence and Precursor (ASAP) model to show how post-incident actions can feed into organisational learning and recovery, helping to build more resilient systems, and why these lessons remain relevant for today’s high-hazard industries.
How SCTA Builds Reliability and Resilience: A Whole-System Approach to Understanding Work
Reliability prevents failure.
Resilience helps us recover from it.
SCTA can strengthen both.
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).
Human Factors in Control of Work Systems
Control of Work (CoW) systems form the backbone of safe operations in high-hazard industries. Yet, their success often hinges on human interaction.
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.
Getting on the Same Page in Cardiac Surgery: How Shared Mental Models Can Save Lives
A fascinating case study explores how “Shared Mental Models” – a concept proven in aviation and military operations – can transform surgical team performance.
Human Factors in Turnarounds: Key findings and lessons learned
Turnarounds are planned events where significant sections of a process plant are shut down to enable maintenance or projects to be carried out. Despite being planned events, they are inherently non-routine and resource intensive.
