Pre-Accident Investigations

ForewordA Context Setting Discussion

Let’s start with a story. Humans have an unusually strong bias towards learning through storytelling. I intend to use this same bias to begin this book. In many ways, this story covers everything that we will discuss in this book: the presence of normal operational information in every event; the belief that had we had access to the right knowledge before a failure happened we would have most certainly avoided the failure; the clear absence of failure identification before the failure started. Read this story, and think about how these ideas could apply to your organization. After all, with a couple of little changes, this story could be your organization’s story.

A colleague of mine who is a noted high explosive ...