The Investigation. Ask what failed, not who failed.
Front
The Investigation
Ask what failed, not who failed
The method of learning from an accident instead of punishing it.
Back
Aviation, railways, and hospital medicine got safer by treating every accident as information. An independent body reconstructs what happened, publishes it, and recommends changes. Where the first question is who to blame, people hide the near misses, and the same accident quietly waits to happen to somebody else.
- The useful question is why a reasonable person did what they did. Almost nobody chooses to cause an accident, so the conditions are usually the cause.
- Checklists came out of this method. They exist because trained experts skip steps under pressure, not because anybody is careless.
Gawande, The Checklist Manifesto (2009)
Keep exploring
Because you read The Investigation.
Normal Accidents
Some failures are built into the design
Failures built into a system rather than caused by somebody's error.
The Backup
Three copies, two kinds, one elsewhere
The rule that turns a lost device into a nuisance instead of a disaster.
Antibiotic Resistance
A cure being used up in slow motion
Bacteria learning to survive the medicines that used to kill them.