How we frame learning opportunities and the language we use is critical: firstly, we need to create the environment for others to learn, and because when we focus on the context and the conditions, we create an empathetic response. This blog looks at what happens when you don't do that.
Learning doesn't happen when we find out people broke the rules, or they deviated from the standards: if that is what caused accidents, we'd have way more deaths than we do. We have to understand the local rationality or influential factors present. That is what the Learning Review helps us to do.
With hindsight, we can look back on events and think that we would have spotted the critical factors leading to the adverse event when those involved didn't. If it was that obvious, it would have been spotted...
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