Interesting article:
Cheers,
Earl
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From Nate Silver’s The Signal and the Noise,
At the bottom what things looked like before an event. The top, what things look like after the event.
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Bad Apples
The Bad Apple Theory is based on the belief that the system in which people work is basically safe and worker errors and mistakes are seen as the cause of the accident. An investigation based on this belief focuses on the workers’ bad decisions or inappropriate behavior and deviation from
written guidance, with a conclusion that the workers failed to adhere to procedures. Because the supervisor’s role is seen as enforcing the rules, the investigation will often focus on supervisory activities and conclude that the supervisor failed to adequately monitor the worker’s performance
and did not correct noncompliant behavior. [Dekker, 2002]16
From the investigation perspective, knowing what the outcome was creates a hindsight bias which makes it difficult to view the event from the perspective of the worker before the accident.
It is easy to blame the worker and difficult to look for weaknesses within the organization or system in which they worked. The pressure to find an obvious cause and quickly finish the investigation can be overpowering.
Source: DOE HANDBOOK
Accident and Operational
Safety Analysi
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