Agree that the strawman I put up is an unlikely situation, but was just to illustrate the point the "blaming" (while the wrong word to describe it) may be valid in some situations and shouldn't prevent learning from occurring at the same time.But, how often is it just a 'recruiting mistake'? — Aaron Marshall
I agree, and a big part of the problem you highlight is when we (either a regulator or a business) try to do both at the same time.There are competing objectives that very rarely sit nicely together with education vs. prosecution... — Aaron Marshall
I think it isn't exactly to move the focus away from human error, but to ensure that human error isn't the only focus. Otherwise we will still be missing a big piece of the puzzle when it comes to understanding the work and what went wrong (or right) - we need to understand why someone made the mistake they made to understand and assess how the rest of the system parts worked together to result in the outcome that eventuated.I find that the issue is than when investigating events, risks, incidents the focus needs to move away from human error and go a bit more in-depth into organizational issues such as process, training methodology, risk assessments, incident investigations, management reviews, etc — TracyRichardson
Agree that the strawman I put up is an unlikely situation, but was just to illustrate the point the "blaming" (while the wrong word to describe it) may be valid in some situations and shouldn't prevent learning from occurring at the same time. — MattD2
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