Conceptual Articles

What makes Trajectories® different is our approach to evaluating the defense-depth-design of systems considering the impact of human behaviors and mechanical failures. These concepts allow you as an organization to prospectively model risk and identify effective risk mitigation strategies related to classes of undesired outcomes.

Human Error is NEVER the Cause

Jens Rasmussen, a pioneer in the field of safety science, explains that we humans investigate until we find a cause that is abnormal, but familiar. It’s like our embedded investigation protocol. You have a flat tire (the bad outcome). You find a nail in your tire (the cause)….

Human Error is NEVER the Cause

There is No Such Thing as a High Reliability Organization

“Become an HRO,” they say. “It’s the secret to becoming highly reliable at what you do.” Many industries suffering from higher than expected rates of failure…

No such thing as HRO

Engineers Chase Reliability; Marketers Chase Zero Harm

Zero. It’s the current safety craze, particularly within those industries that have had questionable safety records. Road safety. Employee safety. Healthcare.  It goes something like this. “Wow, we’ve not been doing well. And it seems we’re all growing comfortable with it….

Engineers Chase Reliability; Marketers Chase Zero Harm

Forget Rules: We Humans are Hazard and Threat Avoiders

Another dissatisfied customer? Another safety event? That’s easy, let’s just write a new rule. Articulate the expectation. Our employees are good people, they’ll follow the rule. Maybe…

Forget Rules: We Humans are Hazard and Threat Avoiders

Every Value Needs a Champion

Never have I seen a more conflicted place than the bedside of a patient. The nurse’s mission is clear: take care of the patient. But then come the competing values: safety, privacy, dignity, financial stewardship…

Every Value Needs a Champion

Don’t Hug from Behind: Because Values trump Rules

When speaking to leaders about organizational culture, I’ll ask them if they have rules around workplace hugging. Their eyes will wander, searching their mental rulebooks, perhaps looking for their VP of Human Resources.

Don’t Hug from Behind: Because Values trump Rules

“No Harm, No Foul” is No Strategy for High Reliability

No harm, no foul. It’s been in our common vocabulary for decades. The Dictionary of Modern Proverbs suggests its source is the phrase “no blood, no foul” used in streetball, a more aggressive form of basketball played back in the 1950’s. In truth,..

“No Harm, No Foul” is No Strategy for High Reliability

Mathematical Dependencies: The Hidden Killer

A commercial airline engine shuts down in flight in the neighborhood of once in every 50,000 hours of operation. That is significantly more hours than a pilot will see in a lifetime of flying. For all practical purposes, a single…

Mathematical Dependencies: The Hidden Killer

Play with Three Dice, When You Can

They are there, in your hand. You can’t see them, you can’t feel them, but they are there just the same. And, at the start of any human activity, you roll one, two, three, maybe even four or five of them onto…

Play with Three Dice, When You Can