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SH190: You can't learn from adverse events if you are going to blame
Manage episode 494013641 series 3516753
Gareth Lock at The Human Diver에서 제공하는 콘텐츠입니다. 에피소드, 그래픽, 팟캐스트 설명을 포함한 모든 팟캐스트 콘텐츠는 Gareth Lock at The Human Diver 또는 해당 팟캐스트 플랫폼 파트너가 직접 업로드하고 제공합니다. 누군가가 귀하의 허락 없이 귀하의 저작물을 사용하고 있다고 생각되는 경우 여기에 설명된 절차를 따르실 수 있습니다 https://ko.player.fm/legal.
In this episode, we explore the role of punishment in learning and accident investigations, challenging the idea that punishment fosters accountability or safety. Drawing from research by Heraghty, Dekker, and Rae, we discuss how punishment often stifles honesty, trust, and meaningful learning by creating a culture of fear. Using real-world examples, like a tragic drysuit diving accident and the grounding of a liveaboard vessel, we examine systemic issues that contribute to failures and how biases like hindsight and severity affect our responses. Instead of focusing on blame, we advocate for systemic, science-based approaches to foster psychological safety, support accountability, and promote learning to prevent future incidents.
Original blog: https://www.thehumandiver.com/blog/blame-or-learn
Links: Modifying an accident process and its justice system: https://www.sciencedirect.com/science/article/abs/pii/S092575352100093X?via%3Dihub
Punishment doesn’t change behaviours associated with errant behaviours: https://www.simplypsychology.org/operant-conditioning.html
Managing accidents using retributive justice mechanisms: https://www.sciencedirect.com/science/article/abs/pii/S0925753520300746?via%3Dihub
Linnea Mills case: https://divernet.com/scuba-news/12m-lawsuit-follows-suit-squeeze-death/
Mission Improbable: Using Fantasy Documents to Tame Disaster: https://www.jstor.org/stable/3791858?seq=1
The likelihood of drift: https://www.thehumandiver.com/blog/being-a-deviant-is-normal
Modifying an accident process and its justice system: https://www.sciencedirect.com/science/article/abs/pii/S092575352100093X?via%3Dihub
CIEHF Guide to Learning from Adverse Events: https://ergonomics.org.uk/resource/learning-from-adverse-events.html
Socorro Vortex grounding: https://www.deeperblue.com/socorro-vortex-liveaboard-runs-aground/
Report from the Danish MAritime Accident Investigation Board: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/
Cognitive biases that limit learning: https://gue.com/blog/drift-is-normal-being-a-deviant-is-normal-heres-why/
Identifying error prone or error producing conditions: https://www.thehumandiver.com/blog/human-error-in-diving-is-it-really-that-simple
Stoney Cove “Safety Stop” case: https://divernet.com/scuba-diving/diving-instructor-cleared-in-safety-stop-death-case/
Sidney Dekker’s Restorative Just Culture Checklist: https://drive.google.com/file/d/1Vkg0o4Fc8XWsAul-mkXNqD5lwokQ0ntP/view?usp=sharing
Tags: English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture, Leadership, Psychological Safety
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