Learning from Success

But is it appropriate in a complex world to maintain a linear view of incident causation? Isn't the road that is not travelled just as instructive to further incident prevention as the road that is actually travelled? Indeed, in many respects, the "lucky" control is more instructive for incident prevention than the failed or absent control. If we adopt that approach, building system resilience is not simply achieved by adding Swiss cheese layers as the orthodox view of the theory may suggest, but also by uncovering and plugging holes within each layer that are reasonably related to the incident although not causally connected to it.

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