Safety culture may be seen as the oil necessary for an efficient safety management system. During the work in HILAS SMS task force some weaknesses in the use of safety culture in practice were identified. A work stream was initiated to identify further weaknesses and suggest remedies for them. The objective of this paper is to discuss some of the weaknesses and propose mitigations. A major suggestion is to actively look for `holes¿ in the safety culture and mitigate them. The `holes¿ could be low-score groups, low-score aspects of safety culture, and critical time-windows. Also the efforts by top management may need to be improved. Also means for feed forward control should be used and further developed as proposed by the new school of resilience engineering. Also when problems with long questionnaires are too big shorter questionnaires could be used complemented by interviews and studies of behaviour and artefacts.@en

When NRI published the first edition of MORT User¿s Manual and Chart in 2002, the only version of the manual then available in the public domain was that written for the United States Department of Energy. Understandably, the DoE edition of the manual was written in American English and referred to documents and organisations that were relatively unknown to people outside of the intended readership. The manual was also ten years old. The first edition of the NRI MORT User¿s Manual provided European users of MORT with a question set in British English. The revisers kept to the structure of the 1992 version of the MORT Chart and stayed close to the concepts of the original (1973) MORT text. The publication of the first edition also meant that the MORT method stayed available in the public domain and accessible via the internet. This second edition arose from a project to translate the MORT user¿s manual and MORT chart into Dutch. This project was undertaken by the NRI Foundation in partnership with the Royal Dutch Navy. Early on in the project, the members of translation team realised that they were investing considerable effort to clarify ¿ in English ¿ the concepts behind some of the questions posed in the manual. In effect, the team were revising the English manual as a necessary prelude to producing a Dutch text. Furthermore, some of these clarifications suggested that changes were needed to the structure of the MORT Tree. To consider these structural changes, the Foundation formed a second team. Over a period of two years, these two teams have reviewed each other¿s ideas until consensus was reached about the changes to the MORT tree and the phrasing of the questions in the manual. In this way, a translation became a revision with a scope wide enough to justify the result as a second edition rather than as a minor revision.@en

In virtually all safety-critical industries the operators of systems have to demonstrate a systematic and thorough consideration of safety. This is increasingly being done by demonstrating that certain goals have been achieved, rather than by simply following prescriptive standards. Such goalbased safety cases could be a valuable tool for reasoning about safety in healthcare organisations, such as hospitals. System-wide safety cases are very complex, and a reasonable approach is to break down the safety argument into sub-system safety cases. In this paper we outline the development of a goalbased top-level argument for demonstrating the safety of a particular class of medical devices (medical beds). We review relevant standards both from healthcare and from other industries, and illustrate how these can inform the development of an appropriate safety argument. Finally, we discuss opportunities and challenges for the development and use of goal-based safety cases in healthcare.@en

This manual describes a method that is based on ¿Events and Causal Factors Analysis¿, ECFA (Buys and Clark, 1995) and attempts to distil refinements of approach that have been collected over the last decade. These refinements were arrived at through the experiences of the authors and by applying criteria and methods published by others (see the bibliography). In order to distinguish this method from its predecessor, it is called ECFA+, Events and Conditional Factors Analysis.@en

This document is published as the result of a project to explore the preconditions for the efficient investigation of accidents and incidents. It is provided as a focus for debate and comment. The ¿Defining Operational Readiness to Investigate¿ project ran between 1995 and 1996 as a partnership between the NRI Foundation and the UK¿s Royal Society for the Prevention of Accidents (RoSPA). This document will be maintained by the Foundation and the authors are keen to hear from any reader with comments and suggestions. Operational Readiness is a philosophy that can be applied to any purposeful system. Readers of this document are encouraged to apply the operational readiness concept to other systems in which they work. Also, although this document is chiefly concerned with the investigation of accidents and incidents related to safety, the contents can be applied to other types of mishap with only little modification.@en