John KingstonApr 30, 20243 min readCuriosity needs time: the effects of stopping the clockInternal investigations can be shallow in richness, relationships, and also time. Without the flow of events, ‘shallow time’ obliges...
John KingstonAug 18, 20222 min readInformation resides in differenceRecently, I looked at an accident in which an experienced person did something unforeseeable. The equipment, procedure and people were...
John KingstonJul 15, 20222 min readPolite Self-InvestigationsIn the UK, there is no statutory duty to investigate occupational accidents. There is, however, a duty to have a valid risk assessment....
John KingstonAug 5, 20211 min readDescribe – then, explainThe NRI foundation maintains the manual on Events and Conditional Factors Analysis. Investigators use it to create rigorous descriptions...
John KingstonJul 20, 20211 min readRecord keeping in UtopiaWise Trevor Kletz advised: “Never remove equipment before you know why it was installed. Never abandon a procedure before you know why it...
John KingstonJul 5, 20211 min readComing to terms... of referenceHow do you get value from internal investigation? Senior managers seldom investigate accidents personally. But, left to their own...
John KingstonJul 1, 20211 min readThe investigation model of last resort?Investigators do the investigations that they can live with; that tends not to be talked about much. Instead, writers and trainers focus...
John KingstonJun 18, 20211 min readMORT: Method, Project, and ProgrammeWhen people say ‘MORT’ they usually mean the method for evaluating safety management. MORT was also a project that, in the 1970s,...
John KingstonJun 15, 20211 min readWorking, but not ready. The accident prone operation.NRI’s white paper on operational readiness presents twelve, linked principles. The first, Nertney’s principle, is to plan and manage any...
John KingstonMay 27, 20211 min readNot quite ERICHaddon’s paper, On the Escape of Tigers, describes an orderly way to design-out the risks of accidents. Even at 50, it’s a great example...
John KingstonMay 27, 20211 min readInvestigation toolsEvery now and then I am asked: “is ‘x’ a good tool?”. My NRI colleagues and I wrote about this some years ago. One conclusion was that...
John KingstonMay 25, 20211 min readProve or ImproveThe parties in a courtroom know the standard of proof for facts that is expected there. It is seldom so clear in the workplace, and often...
John KingstonMay 25, 20211 min readMeasurement can impair foresightIt is easy to set-up measurements, but also to get ensnared by them; this is the warning of the McNamara fallacy. The phrase does no...
John KingstonMay 25, 20211 min read"Good writing is rewriting"A handful of principles can help to make writing readable. It matters, too. My colleagues and I published a paper that showed emergency...
John KingstonMay 25, 20212 min readInvestigate your words“They might as well write the conclusions before investigating the accident,” the senior investigator despaired: “it’s really that bad”....
