Article titled 'Joined up thinking better for Drivers' on femalefirst.co.uk 6 September 2006.
Research by Brunnel University has shown that the coaching and practical on-road assessment and feedback providing by the Institute of Advanced Motorists improves people's driving ability, whilst others do not improve after passing their test, or even deteriorate.
Improvement is put down to having a greater awareness of other road users, road conditions, and infrastructure. But the greatest impact is the ability join these up so that drivers can achieve an overall understanding of potential hazards and the appropriate driver response.
They break the competence into knowledge of what was going on around them, skills applied to the driving tasks, and attitude towards driving.
Andy Brazier
Thursday, September 07, 2006
Wednesday, September 06, 2006
Leading by example
Zoe Thomas writing Sunday Times 'Best Companies' supplement on 3 September 2006
Top tips for leading by example include:
1. Listen to your employees
2. Act on what staff tell you, or explain why you do not agree with their idea
3. Trust your workforce and delegate important jobs to them
4. Trust fellow senior employees
5. Formulate clear company values/principles
6. Live the company values yourself
7. Place the company first, not your own personal ambition
8. Keep meetings with other senior managers to a minimum
9. Communicate decisions arrived at such meetings to all staff
10. Make sure everyone in the company knows who is responsible for what
Top tips for leading by example include:
1. Listen to your employees
2. Act on what staff tell you, or explain why you do not agree with their idea
3. Trust your workforce and delegate important jobs to them
4. Trust fellow senior employees
5. Formulate clear company values/principles
6. Live the company values yourself
7. Place the company first, not your own personal ambition
8. Keep meetings with other senior managers to a minimum
9. Communicate decisions arrived at such meetings to all staff
10. Make sure everyone in the company knows who is responsible for what
Best companies to work for
Article by Zoe Thomas in Sunday Times 'Best Companies' Supplement on 3 September 2006
Eight critical influences on the overall workplace experience are:
1. Leadership: how people feel about the head of the company and the most senior managers
2. Personal growth: to what extent people feel stretched by their job
3. My manager: people's feelings towards their day-to-day managers
4. My company: feelings about the company people work for as opposed to the people they work with
5. My team: people's feelings about their immediate colleagues
6. Wellbeing: how people feel about stress, pressure and the balance between their work and home life
7. Giving something back: how much companies are thought to put back into society and the community
8. Fair deal: how happy employees are with their pay and benefits
Apparently, success in these factors generates "employee engagement" which defines the quality and strength of relationship between the workforce and their organisation.
Andy Brazier
Eight critical influences on the overall workplace experience are:
1. Leadership: how people feel about the head of the company and the most senior managers
2. Personal growth: to what extent people feel stretched by their job
3. My manager: people's feelings towards their day-to-day managers
4. My company: feelings about the company people work for as opposed to the people they work with
5. My team: people's feelings about their immediate colleagues
6. Wellbeing: how people feel about stress, pressure and the balance between their work and home life
7. Giving something back: how much companies are thought to put back into society and the community
8. Fair deal: how happy employees are with their pay and benefits
Apparently, success in these factors generates "employee engagement" which defines the quality and strength of relationship between the workforce and their organisation.
Andy Brazier
Problems with new technology
David Johnson article "Don't wince when the digital revolution behaves like a spoilt brat" in the Sunday Times on 3 September 2006
He describes the newest technology as being "like a wayward child that you want to embrace, even if it will keep spitting you in the eye." This is because companies are more interested in giving us headline-grabbing new features or a new look, without thinking how they will work in practice.
He quotes examples including the new Nokia 6233 mobile phone with a screen you can't read in daylight and the LG chocolate phone with a touch sensitive keypad that performs unwanted actions when your finger hovers over it. Also, rail company Southern introduced an electronic ticket machine that required users to wade through multiple pages and often rejected credit cards late in the sequence, causing huge queues.
Other complaints include website for booking tickets where you are never sure if the transaction has gone through successfully. Items with "known issues" such as a DAB radio that would not turn off or a VCR that could not record when first put on sale.
Also, it doesn't help that different manufacturers use different names for the same basic functions. The name even changes between different models from the same manufacturer.
Andy Brazier
He describes the newest technology as being "like a wayward child that you want to embrace, even if it will keep spitting you in the eye." This is because companies are more interested in giving us headline-grabbing new features or a new look, without thinking how they will work in practice.
He quotes examples including the new Nokia 6233 mobile phone with a screen you can't read in daylight and the LG chocolate phone with a touch sensitive keypad that performs unwanted actions when your finger hovers over it. Also, rail company Southern introduced an electronic ticket machine that required users to wade through multiple pages and often rejected credit cards late in the sequence, causing huge queues.
Other complaints include website for booking tickets where you are never sure if the transaction has gone through successfully. Items with "known issues" such as a DAB radio that would not turn off or a VCR that could not record when first put on sale.
Also, it doesn't help that different manufacturers use different names for the same basic functions. The name even changes between different models from the same manufacturer.
Andy Brazier
Computer Science for Fun
I have been looking around the Computer Science for Fun website. Some really interesting games that introduce useful concepts about error, user interfaces etc. Well worth a look
CS4F Website
Andy Brazier
CS4F Website
Andy Brazier
Everyday errors
Good article on the Computer Science For Fun website about research into pilot error. Includes a space invaders game that can be played on line that induces you to make errors to see if you avoid them.
http://www.dcs.qmul.ac.uk/cs4fn/humanerror/
Web article talks about every day errors that most of us make. The list includes
Forget your change in a shop or from a vending machine?
Forget to take the receipt?
Photocopy something then forget the original.
Forget to switch off the headlights of your car?
Forget to switch off the gas on the cooker.
People are naturally prone to make these errors because they all involve completing the thing you were trying to do: get a drink or chocolate, a photocopy, arrive at the place you were going to, cook the meal, etc. For all of these errors there was an extra thing you had to do after you had completed the main task ... and you forgot to do it. (take the change, take the receipt, switch off the headlights or the gas). Experiments have shown that these errors happen due to working memory overload combined with the structure of the task.
Early cash machines gave back the money first then the card. People regularly forgot their cards. Same error. Now, in Britain at least, the machines always give the card back first. People rarely forget their cards with the redesigned machines. Better design: human error disappears.
Andy Brazier
http://www.dcs.qmul.ac.uk/cs4fn/humanerror/
Web article talks about every day errors that most of us make. The list includes
Forget your change in a shop or from a vending machine?
Forget to take the receipt?
Photocopy something then forget the original.
Forget to switch off the headlights of your car?
Forget to switch off the gas on the cooker.
People are naturally prone to make these errors because they all involve completing the thing you were trying to do: get a drink or chocolate, a photocopy, arrive at the place you were going to, cook the meal, etc. For all of these errors there was an extra thing you had to do after you had completed the main task ... and you forgot to do it. (take the change, take the receipt, switch off the headlights or the gas). Experiments have shown that these errors happen due to working memory overload combined with the structure of the task.
Early cash machines gave back the money first then the card. People regularly forgot their cards. Same error. Now, in Britain at least, the machines always give the card back first. People rarely forget their cards with the redesigned machines. Better design: human error disappears.
Andy Brazier
Friday, September 01, 2006
Back injuries
Very comprehensive article about back injuries, prevention and treatment by Josh Cable
http://www.occupationalhazards.com/articles/15578
"Of the 1.3 million reported lost-time injuries and illnesses in private industry in 2003, sprains and strains – most often involving the back – were far and away the leading type of injury in every major industry sector, accounting for 43 percent of the total lost-time cases, according to the Bureau of Labor Statistics (BLS)"
"While it's not easy to put a nationwide price tag on back injuries, the 2005 Liberty Mutual Workplace Safety Index found injuries caused by overexertion – defined as excessive lifting, pushing, pulling, holding, carrying or throwing an object, all of which are key ingredients of back injuries – cost employers $13.4 billion."
Maintaining the curve is key. It is suggested we unlearn proper use of a out bodies at a young age, around 4 or 5.
http://www.occupationalhazards.com/articles/15578
"Of the 1.3 million reported lost-time injuries and illnesses in private industry in 2003, sprains and strains – most often involving the back – were far and away the leading type of injury in every major industry sector, accounting for 43 percent of the total lost-time cases, according to the Bureau of Labor Statistics (BLS)"
"While it's not easy to put a nationwide price tag on back injuries, the 2005 Liberty Mutual Workplace Safety Index found injuries caused by overexertion – defined as excessive lifting, pushing, pulling, holding, carrying or throwing an object, all of which are key ingredients of back injuries – cost employers $13.4 billion."
Maintaining the curve is key. It is suggested we unlearn proper use of a out bodies at a young age, around 4 or 5.
Motivating ergonomic behaviour
Article by Robert Pater presented June 2006 at ASSE's (American Society of Safety Engineers) annual Professional Development Conference. Summarised here
Many organisation have employed engineering solutions to improve ergonomics. They have been successful, but improvements have plateaued. Behaviours need to really change for further improvement.
Pater states that "leaders incite change by motivating receptivity and trial of new behaviors, transferring critical mental and physical skills and reinforcing improved performance – all with a goal of setting positive, safe default habits." He proposes a seven stage approach
1. Set and assess ergonomic-motivating objectives - realistic expectations
2. Identify barriers to ergonomic receptivity and behavioral change.
3. Energize all - move from just prevention to personal benefits of fitness
4. Spark involvement - simultaneous topdown/bottom-up "scissors" approach
5. Focus on home, as well as work
6. Build critical ergonomic skill sets, both mental and physical
7. Make it (self) reinforcing - publicise plans and success, get everyone talking about it.
To achieve involvement managers can help select the leading ergonomic indicators they deem valuable. Supervisors are involved in setting the timing for and reinforcing action changes. Some employees might be trained to become "peer catalysts," who are agents of ergonomic behavioral change. And all workers can select and monitor personal ergonomic objectives.
Pater lists skills sets that can be taught as
seeing your own level of accepted risk;
directing attention at will;
recalling policies/procedures/techniques;
understanding and applying underlying ergonomic principles;
maximizing leverage to maximize effective strength;
heightening balance;
improving eye-hand coordination;
boosting flexibility/range of motion;
reducing fatigue;
controlling breathing;
effective preparation and recovery methods.
Andy Brazier
Many organisation have employed engineering solutions to improve ergonomics. They have been successful, but improvements have plateaued. Behaviours need to really change for further improvement.
Pater states that "leaders incite change by motivating receptivity and trial of new behaviors, transferring critical mental and physical skills and reinforcing improved performance – all with a goal of setting positive, safe default habits." He proposes a seven stage approach
1. Set and assess ergonomic-motivating objectives - realistic expectations
2. Identify barriers to ergonomic receptivity and behavioral change.
3. Energize all - move from just prevention to personal benefits of fitness
4. Spark involvement - simultaneous topdown/bottom-up "scissors" approach
5. Focus on home, as well as work
6. Build critical ergonomic skill sets, both mental and physical
7. Make it (self) reinforcing - publicise plans and success, get everyone talking about it.
To achieve involvement managers can help select the leading ergonomic indicators they deem valuable. Supervisors are involved in setting the timing for and reinforcing action changes. Some employees might be trained to become "peer catalysts," who are agents of ergonomic behavioral change. And all workers can select and monitor personal ergonomic objectives.
Pater lists skills sets that can be taught as
seeing your own level of accepted risk;
directing attention at will;
recalling policies/procedures/techniques;
understanding and applying underlying ergonomic principles;
maximizing leverage to maximize effective strength;
heightening balance;
improving eye-hand coordination;
boosting flexibility/range of motion;
reducing fatigue;
controlling breathing;
effective preparation and recovery methods.
Andy Brazier
Thursday, August 31, 2006
Allocating blame for cable car crash
Article on BBC site 18 July 2006. Provides more information about the Nevis Range cable car crash that injured 5 people.
http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5189324.stm
I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:
"there must have been human error as the safety systems worked as intended"
"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."
http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5189324.stm
I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:
"there must have been human error as the safety systems worked as intended"
"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."
Red-face spellchecker
Article from Reuters 26 July 2006
here
TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."
Oops
here
TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."
Oops
Pitfalls of nuclear power
Book titled 'Nuclear Power Is Not the Answer' by Dr Helen Caldicott is summarised at this web site
http://www.vheadline.com/readnews.asp?id=65443
Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."
Human error gets several mentions. See quotes below
"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."
And
"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.
http://www.vheadline.com/readnews.asp?id=65443
Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."
Human error gets several mentions. See quotes below
"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."
And
"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.
Repetetive stress injuries (RSI)
Article "Exercise may be the rx for RSI" on LAtimes.com 7 August 2006. Suggests the cost of RSI to US industry may be as much as $100 billion annually if direct and indirect costs of lost productivity and absenteeism are included.
Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.
As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."
Article online at
http://www.latimes.com/features/health/la-he-ergonomics7aug07,0,7236861.story?coll=la-home-health
Similar article at
http://www.insurancejournal.com/news/international/2006/07/25/70711.htm
Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.
As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."
Article online at
http://www.latimes.com/features/health/la-he-ergonomics7aug07,0,7236861.story?coll=la-home-health
Similar article at
http://www.insurancejournal.com/news/international/2006/07/25/70711.htm
Thumb ache from texting
Article in Guardian online on 15 August 2006.
Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."
However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.
http://blogs.guardian.co.uk/mortarboard/2006/08/thumbsoff_thursday.html
Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."
However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.
http://blogs.guardian.co.uk/mortarboard/2006/08/thumbsoff_thursday.html
Blunders by NHS kill thousands of patients a year
Front page of Sunday Telegraph, 27 August 2006.
Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.
Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.
We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.
Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.
Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.
We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.
Meeting mixup
Had one of those heart stopping moments yesterday. It is the last week of the school holidays, and I had taken a day out from work to go out with the family. Mobile phone rings. It is one of my clients. He asks "are you nearly here?"
Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."
Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.
Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.
In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.
Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.
As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.
Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."
Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.
Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.
In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.
Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.
As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.
Monday, August 28, 2006
Drowsy driving
According to this article
http://www.tnn.co.uk/UKNews/plonearticle.2006-08-21.2124105117
Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.
http://www.tnn.co.uk/UKNews/plonearticle.2006-08-21.2124105117
Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.
Egyptian train crash
Reported to have killed 'dozens' when one train went into the back of another. Human error is being cited as the cause, suggesting a driver passed a signal. Interesting to note that the head of the state railway authority was fired and his deputy suspended before the inquiry had reached any conclusions. It seems that the rail authority has been seen as being generally lenient regarding safety for some time, and there is motivation to maintain standard.
http://today.reuters.co.uk/news/articlenews.aspx?type=worldNews&storyID=2006-08-21T193532Z_01_L21330896_RTRUKOC_0_UK-EGYPT-TRAINS.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc=NewsArt-C1-ArticlePage3
http://today.reuters.co.uk/news/articlenews.aspx?type=worldNews&storyID=2006-08-21T193532Z_01_L21330896_RTRUKOC_0_UK-EGYPT-TRAINS.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc=NewsArt-C1-ArticlePage3
Sunday, August 13, 2006
Risk management - new guidance from HSE
I noticed this on the HSE home page a few weeks ago. At first it looked good, examples of how to do risk assessments. However, my view is that a fundamental aspect of risk management is that opportunities to remove hazards, followed by reducing hazards are taken before controls are considered. This seems to be completely overlooked in the examples provided.
I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.
The new guidance is at http://www.hse.gov.uk/risk/index.htm
I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.
The new guidance is at http://www.hse.gov.uk/risk/index.htm
Friday, July 14, 2006
Cable car accident
There has been an accident on the Nevis Range cable car system in Scotland. See article at http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5178870.stm
We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).
It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.
We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).
It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.
Radiation risks
There was a very interesting edition of Horizon on BBC2 last night. See write-up here http://news.bbc.co.uk/1/hi/sci/tech/5173310.stm
Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.
I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.
I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.
ossibly more harmful than the actual exposure.
Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.
I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.
I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.
ossibly more harmful than the actual exposure.
Thursday, July 13, 2006
Emails deleted from server
Apparently PlusNet have wiped a load of emails from their server during a system upgrade. It is estimated 700 GB of data was lost when a a senior engineer mistook the management interface of a live email server for that of a backup server, and erased all the data on the wrong one.
Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."
Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?
Article is at
http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm
Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."
Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?
Article is at
http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm
Basic ergonomics
Although I am a registered member of the ergonomics society (virtually equivalent to being chartered - but the society does not yet have chartership available) I rarely get involved in what I call 'basic ergonomics.' To me this is the occupational health side, whereas I usually deal with major hazard risks and more interested in human error and system safety.
Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33
1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better
Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33
1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better
Tuesday, July 11, 2006
Unable to use the emergency phone
Continuing my theme of problems caused by technology. Talking to some people recently. They have to communicate with an offshore platform. There was a problem with the 'land-line' phone system. Following previous problems, they had been provided with a satellite phone. Unfortunately they had never used it before, and were not sure how to use it. Also, they did not know what number to call to contact the platform.
People seem to assume new technology creates automatic improvement. This is clearly not the case.
People seem to assume new technology creates automatic improvement. This is clearly not the case.
Wednesday, June 28, 2006
Ship sinking - crew unable to use new technology
Article in Risk digest at http://catless.ncl.ac.uk/Risks/24.33.html summarises initial findings of inquiry into sinking of Queen of the North. Ship had a new computer based chart system. Crew did not know how to reduce the illumination level from the screen, which at night caused them problems. Their solution was to switch the display off.
Space probe error
According to an article at www.cnn.com on June 14 2006 and recreated in the risks digest at http://catless.ncl.ac.uk/Risks/24.33.html engineers made a catastrophic error when they put together the Genesis space probe. Apparently they put in gravity switches in backward. These were supposed to deploy a parachute as the probe returned to earth, but instead it crashed to earth and was destroyed. Also, the makers skipped a critical pre-launch test and simply did a paperwork review. It is claimed this was partly due to severe financial constraints caused by competitive tendering process.
Tuesday, June 27, 2006
Handling uncertainty
Interesting article in May 2006 Chemical Engineer by Chris Beale.
includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."
Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.
The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.
includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."
Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.
The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.
Perceptions of management commitment to safety
I come across it very often that people at the sharp end perceive that their managers, although saying the right things, are not really that interested in safety.
An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."
Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.
One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.
I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.
An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."
Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.
One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.
I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.
Speed cameras
I drove past the spot at the weekend where I picked up a speeding ticket a couple of years ago. It is in Caernarfon, North West Wales. The ticket said I was doing 42 mph in a 30 limit
The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.
So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.
I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.
The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.
So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.
I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.
Thursday, June 22, 2006
Risk Aversion
Interesting article in RiskTec's quarterly newsletter Spring 06. See www.risktec.co.uk
There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.
A list of UK examples is provided
A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.
Also, from www.landroverclub.net/Club/HTML/humour_silly_laws.htm and www.dumblaws.com
Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.
There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.
A list of UK examples is provided
A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.
Also, from www.landroverclub.net/Club/HTML/humour_silly_laws.htm and www.dumblaws.com
Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.
Managing workplace transport risk
HSE have a proposed 'route map' out for consultation. It is important because 70 people were killed in accidents involving workplace transport in 2004/05
The route map is divided into four sections
1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities
As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.
As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.
I have sent some comments to HSE. You can do the same by going to
http://consultations.hse.gov.uk/inovem/consult.ti/wptms
The route map is divided into four sections
1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities
As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.
As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.
I have sent some comments to HSE. You can do the same by going to
http://consultations.hse.gov.uk/inovem/consult.ti/wptms
Thursday, June 08, 2006
Why most training doesn't work
Article in June 2006 Chemical Engineer about project management included a paragraph about why the 'obvious' answer for improving management is training, but that most proves to be ineffective.
It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.
In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).
It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.
In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).
Good teams
Article in Appointments section of the Sunday Times on 4 June 2006.
Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.
I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.
Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.
I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.
Tuesday, June 06, 2006
7 July 2005 - emergency plans
Final comments from the 7 July bombing response report. See previous posts.
The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.
Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.
The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.
Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.
7 July 2005 - technology
More from report of the 7 July bombing response report. See previous post.
Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”
I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.
An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.
Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”
I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.
An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.
7 July 2005 - emergency management
The report of the 7 July Review Committee has published it report examining how the multiple bombing in London were handled. It is available at http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/05_06_06_london_bombing.pdf
It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.
This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.
I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.
It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.
This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.
I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.
Monday, June 05, 2006
Isambard Kingdom Brunel
We have just returned from a week's holiday in Bristol. Given that it is 200 years since Brunel was born and his strong links with the city, there was a lot about him in the various museums we visited and at the SS Great Britain (the first large iron hulled steam powered ship).
An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.
I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.
An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.
I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.
Thursday, May 25, 2006
Wikipedia on human factors
There is currently a discussion on www.Wikipedia.org about whether human factors and ergonomics should be merged into one topic. There is quite a difference of opinion. I think this is partly because the terms are used differently in different countries and settings.
The main question seems to be whether ergonomics is more focused on anthropometrics and human factors on cognitive and perceptual factors. Those who support the merge seem to suggest that both terms cover the whole subject. Those that oppose seem to suggest that there is a big overlap, but the different focus constitutes separate subjects.
To see the debate go to http://en.wikipedia.org/wiki/Talk:Human_factors
For those of you who don't know, Wikipedia is an online encyclopedia that is made up through informal collaboration. The idea being that anyone can add or edit, and over time the subjects will evolve to a consensus.
The main question seems to be whether ergonomics is more focused on anthropometrics and human factors on cognitive and perceptual factors. Those who support the merge seem to suggest that both terms cover the whole subject. Those that oppose seem to suggest that there is a big overlap, but the different focus constitutes separate subjects.
To see the debate go to http://en.wikipedia.org/wiki/Talk:Human_factors
For those of you who don't know, Wikipedia is an online encyclopedia that is made up through informal collaboration. The idea being that anyone can add or edit, and over time the subjects will evolve to a consensus.
Friday, May 19, 2006
Safety photo .co.uk
Another good web site for basic health and safety
http://www.safetyphoto.co.uk/
Some useful risk assessment forms. Some of the jokes are good.
http://www.safetyphoto.co.uk/
Some useful risk assessment forms. Some of the jokes are good.
Health and safety for beginners
This looks like a great site for basic health and safety.
http://www.healthandsafetytips.co.uk/About_Us.htm
The downloads look particularly useful. The site is not-for-profit, which is very commendable. Well worth a look.
http://www.healthandsafetytips.co.uk/About_Us.htm
The downloads look particularly useful. The site is not-for-profit, which is very commendable. Well worth a look.
Thursday, May 18, 2006
A classic case of human error
Article on BBC website about the nuclear accident at the Tokaimura processing plant in Japan.
http://news.bbc.co.uk/1/hi/sci/tech/461738.stm
Critical mass was achieved because the technicians put too much material in a container, and it happened to be more enriched than usual. An example of why you need to understand the types of errors that can occur and put appropriate measures in place.
http://news.bbc.co.uk/1/hi/sci/tech/461738.stm
Critical mass was achieved because the technicians put too much material in a container, and it happened to be more enriched than usual. An example of why you need to understand the types of errors that can occur and put appropriate measures in place.
Three categories of ergonomics
A useful overview of ergonomics appeared in an article reporting that Gavriel Salvendy from Purdue University has been internationally honored in the field of ergonomics by Ergonomia, an international journal.
It states:
"The field of ergonomics can be divided into three categories: physical, social and cognitive. The physical area deals with problems involving lifting, pushing and more specifically, with injuries associated with the workplace such as carpal tunnel syndrome. The social area concentrates on the design and composition of group dynamics and the interactions of people. The cognitive area focuses on designing computing systems that match human mental capabilities. These systems understand how humans perform certain tasks and emulates them through artificial intelligence."
Article source http://www.purdueexponent.com/index.php/module/Issue/action/Article/article_id/3935
It states:
"The field of ergonomics can be divided into three categories: physical, social and cognitive. The physical area deals with problems involving lifting, pushing and more specifically, with injuries associated with the workplace such as carpal tunnel syndrome. The social area concentrates on the design and composition of group dynamics and the interactions of people. The cognitive area focuses on designing computing systems that match human mental capabilities. These systems understand how humans perform certain tasks and emulates them through artificial intelligence."
Article source http://www.purdueexponent.com/index.php/module/Issue/action/Article/article_id/3935
Monday, May 15, 2006
Custom sign generator
Found this site. Can't quite think of a practical application at the moment, but could be a fun way of getting messages over. Allows you to add your own text to safety signs, monopoly cards, FBI badges etc.
http://www.customsigngenerator.com/
http://www.customsigngenerator.com/
US Accidents
I have been looking at the US Chemical safety and investigation board's website. Some useful information including video summaries of recent accident investigations, including BP Houston. Well worth a look at:
http://www.csb.gov/index.cfm
http://www.csb.gov/index.cfm
Friday, May 12, 2006
Failure to take up technology changes
Two examples in the office where new technology doesn't quite work as intended.
Network printers seem like a great idea to me. You get a fast, good quality printer that may have additional features like double-sided printing. But people are used to having a printer on their desk, and perceive this to be better than having a network printer. So they either keep hold of their printer or obtain one. This throws the cost-benefit that was made for the change to networked printers. The company either has to stock the ink cartridges for the personal printers in stores, or the employee obtains them via expenses. Also, the company either has to continue providing support for the personal printers, or individuals spend their own time fiddling around.
On a similar note, the move to networks that can be controlled, backed-up etc. Again people perceive it is still better to keep some documents on their own hard drive. This is especially the case after there has been a network outage. Of course the problem is that the hard drives are not backed up. Also, copies start t be held and keeping track of version changes becomes impossible.
In both cases, failure to change behaviour means the technology change does not achieve what it was supposed to.
Network printers seem like a great idea to me. You get a fast, good quality printer that may have additional features like double-sided printing. But people are used to having a printer on their desk, and perceive this to be better than having a network printer. So they either keep hold of their printer or obtain one. This throws the cost-benefit that was made for the change to networked printers. The company either has to stock the ink cartridges for the personal printers in stores, or the employee obtains them via expenses. Also, the company either has to continue providing support for the personal printers, or individuals spend their own time fiddling around.
On a similar note, the move to networks that can be controlled, backed-up etc. Again people perceive it is still better to keep some documents on their own hard drive. This is especially the case after there has been a network outage. Of course the problem is that the hard drives are not backed up. Also, copies start t be held and keeping track of version changes becomes impossible.
In both cases, failure to change behaviour means the technology change does not achieve what it was supposed to.
Monday, May 08, 2006
Daft safety rules
Our house has had a loft conversion, so it occupies 3 floors. Apparently building regulations require it to have self closures on all doors on all floors.
Now I can see the idea and understand it in a house spilt into bed sits or similar. But in a family home it must be much more dangerous. Not only is there the risk of trapping fingers, no family can live with doors closed all the time. So all that happens is that doors get propped or wedged open. This makes it far more difficult to close a door if a fire does occur.
Now I can see the idea and understand it in a house spilt into bed sits or similar. But in a family home it must be much more dangerous. Not only is there the risk of trapping fingers, no family can live with doors closed all the time. So all that happens is that doors get propped or wedged open. This makes it far more difficult to close a door if a fire does occur.
Communication errors
Two jokes that illustrate how the spoken word can cause problems.
First - you have to say this one out loud. There were twenty sick sheep. One dies. How many are left? People will say 25 because they think you said 26 sheep.
Second - a bit saucy. A man was having problems in the bedroom department. His GP had done various tests and given him tablets, but no good. He had seen a psychiatrist, but they were at a loss of what the problem was. So he went to see a witch doctor. He said he had a solution, but it would only work once per year. To get it up he had to say 1-2-3. To get it down 1-2-3-4. That evening the man jumped into bed with his wife and said 1-2-3. His ask wife asks 'what's the 1-2-3-for?'
First - you have to say this one out loud. There were twenty sick sheep. One dies. How many are left? People will say 25 because they think you said 26 sheep.
Second - a bit saucy. A man was having problems in the bedroom department. His GP had done various tests and given him tablets, but no good. He had seen a psychiatrist, but they were at a loss of what the problem was. So he went to see a witch doctor. He said he had a solution, but it would only work once per year. To get it up he had to say 1-2-3. To get it down 1-2-3-4. That evening the man jumped into bed with his wife and said 1-2-3. His ask wife asks 'what's the 1-2-3-for?'
Tuesday, May 02, 2006
Checklist for change
Final piece from 'change management in a week.' see previous posts.
Initial concept
Ask:
Initial concept
Ask:
- what change is required?
- what are we trying to achieve?
- what will be the benefits?
- what will be the costs?
- how long do we have to make the changes?
- what is the likelihood of success?
- what are the alternatives?
- what happens if we do nothing?
Watch out for
- do not get tunnel vision - focus on outcomes and weigh carefully the possible alternatives for achieving them
- do not underestimate obstacles.
Unfreezing
Ask
- What will be on the project team?
- who will be the change manager?
- what need to be done when?
- what are the likely obstacles at each stage?
- how will be create dissatisfaction with the current?
- how will we create a vision of the future?
- what will be the milestones to show progress?
Watch out for
- disguised resistance (people saying yes when they mean no, actions not matching words)
- don't underestimate the task
- do not underallocate resources
- watch the detail
- ensure a sense of urgency is created.
Moving
Ask
- what are the indicators that change is happening?
- are new ways of working/structure being adhered to?
- are the barriers being overcome?
- have significant dissenters been removed or neutralised?
- are people receiving sufficient support, coaching, training?
- do recognition and reward systems match what is being required by the change?
Watch out for
- verify changes are being made
- create and celebrate quick wins
- ensure managers communicate a consistent message (discuss differences of opinion in private)
Refreezing
Ask
- Is the recognition and reward system continuing to support the change?
- have news ways of working become part of the routine?
- has the change delivered the expected benefits?
- what needs to be changes next?
Watch out for
- check that people are not sliding back into old ways of working
- do not celebrate victory too early
- ensure that benefits are being delivered and communicated
Why change is resisted
More from "change management in a week."
There is lack of communication so that people do no
There is lack of communication so that people do no
- understand what the change is
- understand what the change means
- understand why the change is necessary
- understand the urgency
- understand how it fits into the bigger picture
lack of will to change so that people do not
- want to change, they are comfortable with how things are
- believe change will deliver the results
Lack of acceptance of the change process because people
- do not like the way the change is being handled
- are not involved in the decision
- are not consulted
- do not like being told what to do
- thing they are being treated unfairly
- thing others are being treated unfairly
Lack of incentive because
- people do not see any personal advantage from the change
- people do not see improvements in their working terms or conditions
Perception that the new way will be worse because
- the job will become less interesting
- will have less autonomy or flexibility
- reduce social interaction
- break up existing team
Threats of change
- reducing power
- undermining position and status
- undermine personal development
- damage routes for promotion
Perception of change
More from 'change management in a week.' See previous post.
You can see why change that affects people has problems. Someone initiating a change may feel ' the change is only small, no one will lose their jobs and the new organisation will be much more efficient.' The people affected are more likely to think 'the change looks large, any efficiency gain must result in job loses, the work will be different and I am not sure I will like so much and I may not be working with my friends. Where will I be in the pecking order after the change?'
Those being affected are likely to have many unanswered questions. They go through the roller-coaster of denial (it is unnecessary and won't happen), blaming others for making it necessary, blaming themselves for not seeing it coming and getting out sooner, despair as there is nothing they can go, realising it won't go away, giving it a go (trial and error), gaining confidence and finally getting results. Management need to be aware and:
You can see why change that affects people has problems. Someone initiating a change may feel ' the change is only small, no one will lose their jobs and the new organisation will be much more efficient.' The people affected are more likely to think 'the change looks large, any efficiency gain must result in job loses, the work will be different and I am not sure I will like so much and I may not be working with my friends. Where will I be in the pecking order after the change?'
Those being affected are likely to have many unanswered questions. They go through the roller-coaster of denial (it is unnecessary and won't happen), blaming others for making it necessary, blaming themselves for not seeing it coming and getting out sooner, despair as there is nothing they can go, realising it won't go away, giving it a go (trial and error), gaining confidence and finally getting results. Management need to be aware and:
- be prepared and not surprised by the reaction;
- plan for a downturn in performance during transition;
- providing information and support;
- expecting anger and apparently irrational responses;
- conceding on points that do not fundamentally affect the change (giving way);
- helping people experiment with the new ways;
- Setting targets and goals as the situation becomes clear so that people can understand what success looks like.
Good example of different perceptions. Scientist would describe water as a clear, odourless drinkable liquid. People lving next to a polluted river would see it differently.
Change management
I have been reading "Change management in a week" by Mike Bourne and Pippa Bourne under the Chartered Management Institute. I found it quite a good, brief guide to the issues of change management. The "in a week" format is pretty pointless, but never mind.
The book points out that you can take a 'hard' systems view of change by asking:
Some changes are 'harder category whilst others are softer. For hard changes timescales are clearly defined and relatively short, resources and objectives are clearlyn identified, everyone perceives the change in the same way, a relatively small group of easily identifiable people are affected, and the management of the change can be restricted to a small defined group. However, for soft changes it is difficult to define timescales, resource needs and objectives; people have different perceptions about the change and many may be affected and so control is distributed more widely. For hard changes and problems originate internally whilst soft changes it is externally.
Gleicher of Arthur D Little proposed the following formula
K x D x V > C
K = knowledge of what needs to be done
D = dissatisfaction with status quo
V = desirability of vision of the future
C = cost in both material and psychological
The book points out that you can take a 'hard' systems view of change by asking:
- What is the problem?
- What are the alternatives?
- Which alternative gives the best solution?
Some changes are 'harder category whilst others are softer. For hard changes timescales are clearly defined and relatively short, resources and objectives are clearlyn identified, everyone perceives the change in the same way, a relatively small group of easily identifiable people are affected, and the management of the change can be restricted to a small defined group. However, for soft changes it is difficult to define timescales, resource needs and objectives; people have different perceptions about the change and many may be affected and so control is distributed more widely. For hard changes and problems originate internally whilst soft changes it is externally.
Gleicher of Arthur D Little proposed the following formula
K x D x V > C
K = knowledge of what needs to be done
D = dissatisfaction with status quo
V = desirability of vision of the future
C = cost in both material and psychological
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