Abstract
Drawing on their ample experience in high-risk industries, the authors show that a number of major accidents have been preceded by warnings raised by people who attempted, unsuccessfully, to alert actors who had the ability to prevent a danger they perceived. The authors demonstrate that, very often, the dissenting opinions and whistleblowers were not heard due to cultures in which bad news was not welcome, criticism was frowned upon, or where a “shoot the messenger” attitude prevailed. Instead, performance pressures push systems in the direction of failure and lead organizations to reduce their safety margins. As a result, a “new normal” is established, and no significant problems are noticed until it is too late.
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Notes
- 1.
Types of events to be treated, allocation of resources, relationships between the entities implied in the learning process.
- 2.
To understand the direct and root causes of the event requires the collection and the interpretation of objective and subjective data; at this stage, one also considers the real and potential consequences of the event.
- 3.
Safety performance in terms of lost time injury rate.
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Dechy, N., Dien, Y., Marsden, E., Rousseau, JM. (2018). Learning Failures As the Ultimate Root Causes of Accidents. In: Hagen, J. (eds) How Could This Happen?. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-76403-0_6
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