What it takes to become a learning organisation?
I have been told on many occasions that people don’t speak up, they hide, manipulate and even lie to their bosses when things go wrong. Here’s a picture of a woman praying in a temple that caught my eyes while in India. What is she doing and why does it matter to attend to her […]
Are We Learning from Enclosed Space Accidents
I have a special relationship with enclosed spaces. Even the image of an enclosed space makes me phobic. As a young deck boy, I would avoid going into enclosed spaces, make all sorts of excuses, manipulate paperwork, and beg my senior cadet and bosun to swap roles whilst taking on a ‘supervisory’ duty standing by […]
Why the Miracle of the Hudson (Captain Sully) is a lost opportunity to learn from accidents?
The Narrative of Accident Investigations What can we learn from the narratives of accident investigations? And more importantly, what can we learn about our assumptions, worldviews and beliefs in the way we narrate accidents? Are we really learning from our accident narratives? In this article, I will use the example of the Miracle of the […]
Why faith in root cause is not so different from faith in Faith
A week ago, I published a blog on why just culture is a flawed concept. If you didn’t have a chance to read through it, here is an overview. During an investigation, I interviewed a forklift driver who had hurt his leg. I asked him, ‘Khalid, what have you learned from the accident?’ His response […]
Is just culture the answer to preventing accidents?
Some years ago, I came across a ship incident where a bosun (the head of the crew) was put through the Just Culture Process. The claim raised against the bosun was that he had deliberately thrown a hammer on a wall within his workshop. This man did not intend to attack or harm anyone, he […]
Stages of Investigation
Oscar Wilde once said, “The truth is rarely pure and never simple.” And so accident reports eventually settle at giving people a meaning that appeals to them and maintaining social and political order. In walking the delicate balance between truth and fantasy, some tend to do a better job than others. Here’s a framework to […]
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 […]
North Sea collision: the making of a scapegoat
On 10th March 2025, the Solong collided with Stena Immaculate in the North Sea area. In just over a day, the captain was arrested and within less than a week, Captain Vladimir Motin was publicly named and charged with gross negligence for manslaughter over the death of a crew member. Investigations (legal, criminal or […]
Why DEI caused an accident? Understanding Trump’s reaction to the Washington mid-air Collision
In less than 12 hours, the president of United States appears on the press and turns an ambiguous situation into a simple narrative. It’s the incompetence of people who were hired for their skin colour, sex, caste, creed and physiology. DEI (diversity, equality and inclusion) caused the Washington midair collision. How did […]