Systems thinking tells us that human error, violations and technology failures result from poorly designed and managed work systems. To help us understand and prevent injuries and incidents, incident reporting systems must be capable of collecting data on contributory factors from across the overall work system, in addition to factors relating to the immediate context of the event (e.g. front-line workers, environment, and equipment).
This book describes how to design a practical, usable incident reporting system based on this approach. The book contains all the information needed to effectively design and implement a new incident reporting system underpinned by systems thinking. It also provides guidance on how to evaluate and improve existing incident reporting systems so they are practical for users, collect good quality data, and reflect the principles of systems thinking.
- Highlights the key principles of systems thinking for designing incident reporting systems
- Outlines a process for developing and testing incident reporting systems
- Describes how to evaluate incident reporting systems to ensure they are practical, usable, and collect good quality data
- Provides detailed guidance on how to analyze incident data, and translate the findings into appropriate incident prevention strategies
1. Systems Thinking and Incident Causation. 2. Systems Thinking and Incident Analysis. 3. A Process Model for Developing an Incident Reporting System. 4. Understanding the Context. 5. Identifying the Needs and Priorities of End Users. 6. Adapting Accimap for Use in an Incident Reporting System. 7. Evaluating Reliability and Validity. 8. Designing a Prototype Incident Reporting System. 9. Evaluating Usability. 10. Evaluating Data Quality. 11. Outputs from the Development Process – UPLOADS. 12. Analyzing Incident Data. 13. Designing Incident Prevention Strategies. 14. Lessons Learned, Future Research Directions, and the Incident Reporting Systems of Tomorrow. Appendix A. UPLOADS Contributing Factor Classification Scheme. Appendix B. Examples of Coding Tasks for Reliability and Validity Assessments. Appendix C. UPLOADS Incident Report Form. Appendix D. Training Manual: The UPLOADS Approach to Accident Analysis.
"Dr. Natassia Goode and colleagues have created an important resource, narrowing the research-practice gap. All readers, whether ergonomics and human factors specialists or OHS or safety science practitioners, will find much to stimulate their thinking. It demonstrates that it is possible to take an evidence-based approach to incident reporting and investigation to assist learning from incidents. Whether you are developing a new incident reporting system or modifying your current workplace system, this book contains the theory and practical advice to assist with meaningful and sustainable system redesign."
—Alison Gembarovski, Ergonomics and OHS Practitioner
"With Translating Systems Thinking into Practice, authors Goode, Salmon, Lenné and Finch have taken on a daunting task: to convey the nuances of a quite a complex and layered subject matter in a way that makes it relatable and usable for industry practitioners and scholars alike — and all in a single, 288-page volume. Thankfully, they deliver on the promise, and with more than a little style.
There’s more than a bit of providence in the creation of this volume. The authors have a long history with much of what they share, and the book is a recapitulation of a research program edited in a way that makes it relatable to a much broader audience. I daresay that those who already know the authors’ work may be familiar much of the information in the book, but it’s still nice to have it all packaged up in the one volume. Systems Thinking has been around for a while but has less hold in industry than it does in academia, more so with certain disciplines who still eye it with suspicion. Part of the reason may be that it’s been tarnished by negative strokes of the human factors-brush, but it can also be somewhat impenetrable and theoretically dense — a different language for some — which is what made this book stand out so much to me."
—Australian & New Zealand Journal of Health, Safety and Environment 2018 Issue, copyright in the review is held by CCH Australia Limited
"Overall, this is an excellent book by four researchers with very significant experience in the field. The book targets a fairly small target audience but has a unique selling point: it simply provides more information on developing incident reporting systems, in a user-friendly way, than can be found anywhere else. If you are responsible for developing new incident reporting systems, or evaluating and improving existing systems, then time spend reading this book will yield enormous benefits for learning from incidents."
—Steven Shorrock, Chartered Psychologist, Chartered Ergonomist and Human Factors Specialist, Eurocontrol