A Safety II approach to investigations with Mark Alston

A Safety II approach to investigations presented by Mark Alston (Investigations Differently) recorded at the Safety II in Practice Workshop with Erik Hollnagel in February 2020.

[SyamsulArifinKLH]

the Safety I approach can still be effective if the recommendation is focus on the engineering modification of the ramp

[lutan]

A well-constructed PEEPO will capture these without a complicated timeline. Work as intended (what the procedure states you have to do). Work as normal (how the practice may have crept due to workers understanding that there is a better way of doing the job) and work as done (what the people actually did at the time of the incident being examined). Under People what the directly involved persons did (work as done). Under Procedures (work as intended) and under Organisation (work as normal) examining potential workaround or habit practices that have developed.

If investigators struggle with a basic timeline (that works for all levels of investigations!), a more complex timeline won't make it any better!

[mickroberts]

Those are not why's ... but actually yes they are. Call them conditions but if you do your 5 why's well, you will discover these facts anyway. So we should do 3 timelines ... LOL. All of this can be done with an existing systems of the investigator is competent