Chapter 38. Accident Investigation—Missed Opportunities
If the origin of the human mind is to be understood, it is important to be able to identify signals of distinctly non-human behaviour. Lack of innovation is one of them.—Roger Lewis, The Origin of Modern Humans
Almost all the accidents described in this book need not have occurred. Similar ones have happened before, and accounts of them have been published. Someone knew how to prevent them even if the people on the job at the time did not. This suggests that there is something seriously wrong with our accident investigations, safety training, and the availability of information.
Having paid the price of an accident, minor or serious (or narrowly missed), we should use the opportunity ...
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