From: LaRosa, Rob
A different perspective. A discussion about "common sense" for this and nearly all other incidents has little value. To me, "common sense" as a finding in an incident investigation is biased, suggests blame, and provides no basis for effective and sustainable solutions. The same is true for: "human error", "poor judgment", or "inattention". Sidney Dekker's said it best in "The Field Guide to Understanding Human Error" : "Explaining one error (e.g. operator error) by pointing to another (inadequate supervision, deficient management, bad design) does not explain anything. It only judges other people for not doing what you, in hindsight, think they should have done." In the same book, he later states: "Problems result from your organization's real complexity - not some apparent simplicity (e.g. somebody's inattention)." One suggestion would be to critically evaluate severe injury/fatality risks and mitigations in open and honest discussions. It takes individuals from many areas/departments to conduct meaningful assessments and sustain the mitigations. Rob LaRosa Lennox International Inc.
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