# Nancy Leveson

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Louis Bertrand P.Eng speaks about the Pickering nuclear power plant

Louis Bertrand is a long time resident of Durham Region, east of Toronto, home to 9 currently working CANDU reactors. His background is electrical engineering, specializing in electronics and firmware, the software that gives electronic devices their smarts. He currently is a full time professor in…

Therac-25, buggy software that killed.

I look at the Therac-25 incidents, a devastating collection of software failures that often rank in the top 10 of civilian radiation accidents. The Therac-25 radiation therapy device killed or injured 6 people across Canada and the United States. I look into the bugs, why the manufacturer didn't fi…

The Critical Steps in Workplace Safety

In this episode, Mary Conquest speaks with Tony Muschara, a Human and Organizational Performance (HOP) specialist and owner of Mushara Error Management Consulting. He’s also the author of several Safety books, including ‘Risk-based Thinking’, and its follow-up ‘Critical Steps’ -  which is the main…

Where Is the System?

How can health care address the systemic challenges that have impeded progress on safety for decades? What lessons can be learned from other industries that have made safety a top priority? Join host Karen Wolk Feinstein and guests Nancy Leveson, professor, engineer, and systems safety expert, and …

The Curse of Flexibility

In this segment, Nancy Leveson joins Philip Reiner and Peter Hayes to make the case that using conservative techniques and avoiding unnecessarily complex software in critical functions in NC3 systems circumvented nuclear catastrophe in the past. Today, she concludes, a new approach is needed that a…

SH181: “Blame is the enemy of safety” - moving from blaming to learning

Mistakes, slips, and lapses are a natural part of human performance, influenced by factors like training, time pressures, and equipment design. While rule-breaking may seem deliberate, it's often shaped by context, social pressures, and the perceived benefits of deviation. Biases like hindsight, ou…

Root Cause Analysis vs. Resilience Engineering w/special guest Lorin Hochstein

A history of the 5 whys and root cause analysis from papers Some critiques of the 5 whys: From John Allspaw: https://www.oreilly.com/radar/the-infinite-hows/ From Alan J Card: https://qualitysafety.bmj.com/content/26/8/671 James Reason and the Swiss Cheese Model:  https://pmc.ncbi.nlm.nih.gov/…

🎙️ Episode 12: Engineering a Safer World through Systems Thinking

Explore the topics of software safety — from Chain-of-Events to System-Theoretic Accident Models. About the Guest: Dr. Nancy Leveson is a professor at MIT and one of the world’s leading voices in system and software safety. Since founding the field of software safety in 1980, she has developed the…

Ep.87 What exactly is Systems Thinking?

We will review each section of Leveson’s paper and discuss how she sets each section up by stating a general assumption and then proceeds to break that assumption down.We will discuss her analysis of: Safety vs. Reliability Retrospective vs. Prospective Analysis Three Levels of Accident Causes: Pr…

Ep.86 Do we have adequate models of accident causation?

We will discuss how other safety science researchers have designed theories that use Rasmussen’s concepts, the major takeaways from Rasmussen’s article, and how safety professionals can use these theories to analyze and improve systems in their own organizations today.   Discussion Points: Rasmuss…