granted. In incident investigations we regard it as irrelevant. How can that be? That is the moment when we are most vulnerable. When we all feel we are to blame. That we have somehow contributed to the incident. Pausing to reflect on success and recognise what we did right can ease much of that. If the focus of incident investigation remains solely on what went wrong, it is inevitable that it is about blame. Even in organisations where a just culture is in place, the singular focus on the negative behaviour can be detrimental to the overall functioning of the system. It is also a missed opportunity. Most effective innovations and discoveries were born out of unintended acts -observing the consequences of a deviation from normal procedure and learning from it. The same is also true of cooking recipes. Explanation is a key to improvement. While such behaviour should not necessarily be encouraged because its consequences are unpredictable, as any amateur cook well knows, where the experimentation works in that it avoided or tempered the effects of an incident we should explore it, understand it and celebrate it. As Dekker (2011) observes: "Complex systems can remain resilient if they retain diversity: the emergence of innovative strategies can be enhanced by ensuring diversity. Diversity also begets diversity: with more inputs into problem assessment, more responses get generated, and new approaches can even grow as the combination of those inputs." 5 F vi In one of our incident investigations, a worker survived a 20-metre fall in a mobile plant principally because, contrary to procedures, he had not buckled his seatbelt. On balance, more lives would be lost by failing to buckle a seatbelt than from doing so. But this life was saved for that reason. Shouldn't we learn from that and attempt to improve the design of our plant? Even if someone did something wrong that worked, we need to understand why it worked so we can capture its positive features. That, in essence, is what Reason (1997) 6 F vii was describing in the flexible culture component of his safety culture model. The empowerment of well-trained workers to make decisions that deviate from normal procedures, but that are consistent with the objectives of the procedures. Once those decisions are made, we need to then understand why they worked. That is where asking "what went right" comes in. The seriousness of, and the learning opportunities which can be garnered from, an event should not be downplayed just because the event does not itself result in injury or damage to plant. To the contrary, near misses present valuable opportunities to learn from mistakes and system deficiencies. In order to avoid disaster it is necessary to understand the risks that arise within an organisation. To allow this, a culture of reporting must be encouraged within the organisation. Without a reporting culture, an organisation will be unable to gather information of incidents that have occurred and will be unable to discover the cause of incidents. Underreporting of near misses will hide issues that can be remedied before the problem develops into a disaster. "we should investigate all accidents, including those that do not result in serious injury or damage, as valuable lessons can be learnt from them. 'Near misses', as they are often called are warnings of coming events. We ignore them at our peril, as next time the incidents occur the consequences may be more serious". 7 F viii Part of the difficulty of encouraging incident reporting and thereby creating a reporting culture is that incident investigation findings are invariably negative in outlook and approach. No matter the rhetoric As Kletz (2001) observes:
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