Safety Thought of the Week… Why we can’t simply investigate accidents and near-misses as our sole means to improving safety

“Very few unsafe acts will result in damage or injury. In a highly protected system, the probability that the consequences of an isolated action will penetrate the various layers of defense is vanishingly small. Several causal factors are required to create a ‘trajectory of opportunity’ through these multiple defenses. Many of the causal contributions will...

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