we ask what went right 5 times in our case studies below) in order to build a comprehensive picture of what worked.
Would we replicate this success in avoiding a similar incident in future? Or were these lucky adaptations on the day?
o What if the consequences were different? o What if the process/system was different? o What if the environment was different? o What if the plant was different? o What if the operator was different?
How can we systematise the learnings so we repeat our success?
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