After Sully is it time for Dali?
Be prepared for Hollywood’s next blockbuster The Dali news release by the National Transportation Safety Board (NTSB) reads a bit like ‘the Miracle of the Hudson Bay River’ (Captain Sully). Linear, simplistic, exaggerated. Is this going to be another Hollywood blockbuster? Some excerpts from the report and their meanings: ‘a single loose wire on the […]
An important lesson in humility, curiosity and how to avoid a blame culture
In every artefacts and across cultures – planes, ships, hospitals, cathedrals, museums or memorials, there are three things to remember: ✅ Do not always blame those who design the system. It is not always easy to figure out the end users and their needs. ✅ Never assume who holds the power. It is usually not […]
How to sleep well at night
Last night I was driven by an old taxi driver (of Iraqi origin) from the airport to the hotel. First thing as I got inside the car, he said, ‘You are my 4th customer in the last 12 hours.’ As we moved further out and he kept repeating himself. ‘You are my 4th customer in […]
Why are we not learning from accidents?
Look at the four monkeys. These are four universal patterns of our typical responses to people involved in accidents. Sympathising – Poor you Mocking – Silly you Blaming – I’ve got you Problem solving – I’ll fix you What is common across all these patterns is a sense of moral superiority – not only that […]
Is root cause analysis much different from witch-hunt?
For the last six years I have been conducting several workshops on Learning from Accidents, and I’ve noticed all sorts of questions. Here’s one from a ship manager who caught me as I was finishing a session on the Costa Concordia accident. “Tell me honestly, okay”, he said, “was a breath analysis test done on […]