Nascent attempt at using Foam to curate and leverage a personal memex
Blame is the enemy of safety. Focus should be on understanding how the system behavior as a whole contributed to the loss and not on who or what to blame for it
@worrydream tweet citing Engineering a Safe World: Systems thinking applied to safety
And a bit more
When trying to understand operator contributions to accidents, just as with overcoming hindsight bias, it is more helpful in learning how to prevent future accidents to focus –not– on what the operators did “wrong” but on why it made sense for them to behave that way under those conditions
