In-depth Analysis

A detailed story offers the possibility of a detailed analysis, which is the next step on the road to High Reliability and/or High Quality. Quite often the analysis of an occurrence stops the moment a violation of rules and/or procedures is found. When we face mala fide behavior, thus gross negligence or criminal intent, that may indeed be sufficient. It will yield a basic, although rather low, level of safety.

However this is the wrong approach when dealing with bona fide behavior. Which is far more likely to be the case in normal organizations with normal people doing normal work. The better approach then is trying to find underlying causes, like for instance inadequate training, maintenance or information.

But the best insights and thus the best opportunities for learning come from trying to understand, given the situation the actors were in and the necessarily limited information and time they had, why they believed the action they took was the right way to go, while we after the fact clearly see that their actions were wrong.

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