A10.16
Accident investigation and error reporting
Cards in this group · 4
- A10.16.1Knowing how it ended makes an investigator misjudge a decision that was reasonable at the time
- A10.16.2Naming one root cause usually hides several factors that combined to cause the accident
- A10.16.3People report mistakes promptly only when it's easy to do and doesn't invite punishment
- A10.16.4Asking who's to blame steers an investigation away from what the system could fix