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SH196: They broke the rules! So...?
Manage episode 497866858 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.
When diving accidents occur, the immediate response often blames rule-breaking, but reality is far more complex. Rules are designed to enhance safety, yet accidents can happen even when rules are followed—and sometimes rules are broken without incident. Diving operations occur within a web of technical, social, and cultural conditions, which can provoke deviations. This highlights the gap between “work as imagined” (rules and procedures) and “work as done” (real-world practice). Understanding why rules are broken requires looking at the system rather than focusing solely on individuals. A Just Culture, where context-rich stories can be shared without fear of punishment, helps address underlying issues and drives meaningful improvements in safety. Punishment alone rarely deters rule-breaking if systemic conditions remain unchanged.
Original blog: https://www.thehumandiver.com/blog/they-broke-the-rules
Links: Root Cause blog: https://www.thehumandiver.com/blog/the-root-cause-of-an-accident
Identifying violation-provoking conditions in a healthcare setting: https://pubmed.ncbi.nlm.nih.gov/18941971/
The Extent of Conditions: https://preaccidentpodcast.podbean.com/e/papod-399-the-extent-of-condition-episode/
Normalisation of Deviance from the Challenger launch decision: https://www.amazon.co.uk/Challenger-Launch-Decision-Technology-Deviance/dp/0226851761
Tags: English, Decision-Making, Gareth Lock, Just Culture, Normalisation of Deviance, Normalization of Deviance
218 에피소드
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