Learning from failure.
WHY IT MATTERS
Systems fail. How an organisation responds determines whether it improves.
WHAT BLAME PRODUCES
Hidden problems Delayed reporting People avoiding risky but necessary work
WHAT THAT COSTS
Far more than any individual mistake.
WHAT TO ESTABLISH
That reporting a problem is always the right action That nobody is punished for an honest mistake That the question is what allowed it, not who did it
WHAT TO ASK AFTER AN INCIDENT
What happened Why it was possible Why it was not caught How long it took to notice What would prevent it
WHAT NOT TO CONCLUDE
That someone should have been more careful.
WHY
A system depending on nobody making a mistake will fail.
WHAT TO PRODUCE
Changes to the system, not to expectations of people.
WHAT TO RECORD
The incident, the cause, and what changed.
WHAT TO SHARE
Both, openly.
