The blameless approach to understanding how things go wrong
from Fast Company
Most traditional accident investigations tend to focus on discovering things around an event that never actually happened. In an attempt to prevent future accidents, there is an underlying assumption for this somewhat peculiar emphasis, which is: Someone did not do something they should have, according to someone else. Through this lens, what generally surfaces in investigations are findings about what people did not do (pay attention, make the right decision, etc.) rather than what they actually did. Unfortunately, this approach does not result in the safer and improved future we want.
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