Dynamic Learning from Accidents
Bridging the gap between accident investigations and learning
We need to investigate accidents. To get feedback from reality. To understand what went right and what went wrong. To determine how mishaps can be prevented in the future and successes can be disseminated.
We are willing to learn from mistakes and to avoid repeating them. We choose to start in reality, not in modeling or theories. We start with the unexpected, the unforeseen. We do not primarily create barriers for repetition of similar accidents, but try to remove barriers for learning in order to understand why systems function as they do and what can be done about the situation.
Why, then, do accidents repeat themselves? Why can accidents, incidents and undesirable events emerge as unforeseen surprises? Technology, organizations and people failed to execute what was originally planned, were unaware of limitations and assumptions and did what they thought was reasonable.
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