a complex system. After all, things rarely happen twice in exactly the same way, since the complex system itself is always in evolution, in flux." 8 F ix
The utility of the lessons, therefore, is translated into motherhood statements about safety leadership and safety culture without any specific means of achieving that in the localised context. That is not to say that those lessons have no value or meaning. They do. The issue is, can we extract more from our incident investigations? Can we derive practical lessons of real meaning, value and application, and can we do this on a regular and systematic basis? It may be more useful to find out how a potential serious incident became a near miss. Or how consequences of an incident were tempered, rather than just finding out what caused the incident. A better understanding of "what went right" can assist in creating a more resilient system. The attraction with asking "what went right?" is its positive character. We know that positive reinforcement is the most important principle of behaviour and a key element of most behaviour change programs (as discussed above). 9 F x So what would a more positive methodology, based on learning from success look like? We provide some thoughts in the next section below.
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