death certificates

Bob Gorman bgorman at KNCELL.ORG
Fri May 6 12:09:38 UTC 2016


On 5/5/2016 7:50 PM, Elias Peter wrote:
> As long as there is the default attitude that ‘someone is at 
> fault’ we will never make much progress. The default attitude 
> HAS to be that everyone is doing the best they can with the 
> skills and training and system available, and that the FIRST 
> (and second and third…) thing to look at with an error, or a 
> near-error, is how to we change the system to make this error 
> less likely to happen next time.
You mention 'near-error'. Aviation faced many similar challenges 
as medicine. Pilots, like doctors, don't want to admit errors, 
especially publicly. But when the context becomes 'preventing 
future errors' things change for the better.
Aviation made a big step forward in prevent crashes when they 
stopped counting only crashes and started investigating 
'near-misses' We could chose to do the same...

Bob








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