I wasn't really very surprised to find out that someone else had been thinking about a narrative database in terms of Aviation Safety. My experience with the Defence Aviation Safety Database is that it gets very wound up over the details and processes. For example, a defective part requires a defect investigation; an insufficient publication needs an amendment. Apart from the occasional question of whether the support systems are sufficient to respond to a booming safety culture that reports every near miss and even the nearly near miss etc, there is the murky circumstances where there was not necessarily a root cause. So this sets us a scene that you have to report a safety event, it is expected to have a root cause or several and something has to be done about it. So apart from a spiralling process driven bureaucracy it becomes unattractive for a person to engage in the safety reporting and thus the system ceases to be useful.
A reasonable person could potentially see that the bureaucratic overheads of telling your story might actually prevent the lesson being learnt. I say this with knowledge of Sensemaker but are there ways of adjusting the micro-culture to talk about its failure and thus change the system we have into something more useful, from the ground up?
Showing posts with label Safety. Show all posts
Showing posts with label Safety. Show all posts
Thursday, July 31, 2008
Tuesday, July 29, 2008
Just a thought
First of all, I am speaking without any authority at all (thank you Technorati)... but I thought it was basic that if you want a safe and undistracted workplace then you probably don't want to threaten the maintenance engineers' jobs.
Does Joyce know what he is getting into?
Does Joyce know what he is getting into?
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