Originally Posted by
safetypee
S-Pee;
thanks for the links that includes Erik Holnagels work. Erik is one of the leaders in the field of stochastic system behaviour and safety. He established years ago the concept of FRAM, which has altered subtly over the years but still gives a rational view of the world in contrast to the rather simplistic linear or quasi linear models of causation that has underpinned HF/CRM/SMS development of the industry for the last 35 years. The downside of non linear causation is that safety managers have to alter their way of looking at the world, and the limitations of pure compliance has to be comprehended. To take advantage of non linear causation, system observers need to ascertain the extent of variation that exists between their assumption of the system behaviour and what is happening in the real world. That takes rather more care in observation than pure compliance does.
To continue to consider critical processes as simplistic models limits the ability to avoid being in the bandaids on bandaids routine that most management by exception results in. As often as not, our fixes do not work quite as advertised, the current apparent dismay and wailing over apparent erosion of flying skills is an obvious example.