Titlebook: How Could This Happen?; Managing Errors in O Jan U. Hagen Book 2018 The Editor(s) (if applicable) and The Author(s) 2018 organizational lea

一骂死割除

FLIRT

Errors and Learning for Safety: Creating Uncertainty As an Underlying Mechanism,collide with an organization’s concerns about proving that they are safe. As the author shows, when decisions are made on how uncertainty should best be managed for particular work processes, stability and flexibility requirements need to be analyzed in view of the specific necessities for control a

名义上

When Silence Is Not Golden,ncidents, we need to understand personal perceptions of risk in order to mitigate the worries and fears involved. We must demonstrate that the benefits of speaking up are indeed greater than the perceived personal costs involved. The authors show that speaking up has to be encouraged constantly for

Loathe

被诅咒的人

演讲

Learning Failures As the Ultimate Root Causes of Accidents,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

磨碎

LAITY

令人不快

可耕种

Open Error Communication in a High-Consequence Industry,cy to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis,