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Last Line of Defence

kelvintop-set News

There have been references lately on LinkedIn to how useful, exemplary and positive it is to talk about one’s failures in terms of learning from mistakes. This demonstrates that success can follow failure, and indeed often does, if the lessons are sought, studied and used. Admitting to error, however, is made more difficult in environments where there is a ‘blame’ …

‘Rage Against the Machine’? – What Automation Means for Human Error

kelvintop-set News

The increasing pace towards automation of industry and the workplace can only be a good thing, especially in terms of business and safety. Machines and computers are more efficient after all, and don’t make mistakes like humans do. But, as was observed in the Industrial Revolution of the early nineteenth century, where industrial processes replaced hand production methods, such radical …

Investigating Instrument Readings

An Instrumental Account of Instrumental Readings

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In many investigations, the contribution of instrumental readings plays a part. So just what do instruments tell us?  How accurate, reliable and precise are they? And what do these words mean anyway?  We all use instruments every day, and think nothing of it. The most common perhaps being clocks, watches, thermometers and speedometers. But do we stop to think about …

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A TOP-SET Mindset is a Growth Mindset

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‘To err is human’ – it’s all about how we respond. Originally stemming from research by psychologist, Carol Dweck, into individual learning and responses to failure, the concept of a ‘growth versus fixed mindset’ is now moving from being embraced by schools, to being applied in organisations and the business environment. It is easy to see why it could be relevant …

Learning Teams… a new idea or just old ideas repackaged?

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The concept of learning teams is a great step forward but far from new. Involvement of diverse teams in the investigation process is vital to effective outcomes. The purpose of investigating is to learn from incidents and to make improvements in systems, processes and operations. Kelvin TOP-SET has been operating for well over 30 years and the principle of working in diverse …

‘Nothing is true but change, nothing abides…’

kelvintop-set News

The main aim of our business is to teach people how to think, how to problem solve, how to investigate the causes of events, and learn from them and from the past. That’s why a knowledge and understanding of history is so very important. To that end I read a great deal. This week’s reading has been particularly enlightening and …

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Communication is the key

kelvintop-set News

Human factors are at the heart of all major offshore incidents, indeed all incidents, an investigation expert has recently stated. David Ramsay, group managing director of industry specialists Kelvin TOP-SET, made the comments as he was reflecting on the 30th anniversary of the Piper Alpha disaster. He said that while technical faults do occur, ultimately these arise from a combination …

A ‘No Blame’ Culture Misunderstood

kelvintop-set News

Two true stories: 1.              A doctor administered the wrong drug in error and a patient died.  2.              A helicopter pilot put the wrong fuel in the fuel tank and the engine stopped mid-air. Fortunately, he was able to land the helicopter safely, and no one died. The doctor was administering an anaesthetic drug, and had two syringes on his tray, …

Investigation – by any Other Name?

kelvintop-set News

Every cloud has a silver lining. I have had the misfortune (good fortune?) to have surgery four times since July 2017. Pain and inconvenience aside, and I am well on the way to complete recovery now, it was an unexpected opportunity (and pleasure) to observe another sector in action. Many times daily I had the opportunity to watch nursing staff …

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When it Really Matters: How Safe are Your People?

kelvintop-set News

Making things better and constant improvement is all part of good management and professionalism. Relating this to incidents, one can see that successful outcomes from even the most extreme events are down to good teamwork, communication and professionalism, achieved through training and best practice. Clearly, though, in all extreme situations people are tested and we don’t know how any of …