The Field Guide › Trails › Safety & Learning from Disasters
From a Swedish warship in 1628 to the modern science of catastrophe. How the study of disaster moved from blaming components to understanding systems.
Kessler, Bierly and Gopalakrishnan use the sinking of the Swedish warship Vasa, which capsized and sank within minutes of leaving harbour on its maiden voyage in 1628, as a case study in how ambitiou…
The founding text of Normal Accident Theory, built to explain why certain systems generate catastrophic failures that no amount of operator training or safety procedure eliminates.
Weick's analysis of the 1977 Tenerife runway collision, in which a KLM 747 began its take-off roll while a Pan Am 747 was still on the runway and 583 people died, is one of the founding texts of the…
On the night of 6 July 1988 the offshore platform Piper Alpha caught fire in the North Sea and 167 people died, in what remains the worst disaster in the history of the offshore oil industry.
Reader and O'Connor take the Deepwater Horizon blowout of April 2010, which killed eleven people and produced the largest marine oil spill in history, and do what the official inquiries did not: they…
Introduced 'collective mind' — the way groups develop heedful interrelating, a form of attentive, connected action that makes complex systems reliable.
Diane Vaughan's ten-year historical ethnography of the decision to launch the Space Shuttle Challenger in January 1986, and the origin of 'normalization of deviance', one of the most widely cited con…
The BMJ paper that brought the Swiss Cheese model and the person vs system approach to a clinical audience.
A review of the growing phenomenon of criminal prosecution following professional mistakes in aviation and healthcare.
Develops and validates the Safety Organizing Scale (SOS), a 9-item self-report measure of the concrete behaviours that constitute a unit-level safety culture, addressing a real gap in the prior liter…
The canonical white paper articulating the Safety-I to Safety-II transition.
An integrative review of the organisational-error literature (some sixty-five studies across twenty-five years) that reads error research through three lenses and, in doing so, becomes the corpus's a…
Kernick writes this book from an unusual and exacting vantage point: she lived on the twenty-first floor of Grenfell Tower from 2011 to 2014, watched it burn on 14 June 2017, and lost seven former ne…
Read, Shorrock, Walker and Salmon review sixty years of thinking about human error, and the arc they trace is the one this map cares about most: the slow migration from blaming the person to interrog…