Building Resilience: How to Learn More from Incidents
summary
Research-backed claim: incidents reveal both prevention gaps and response weaknesses, so investigate design and context, not blame. Shows the B-17 case where confusing gear/flap controls are fixed by a glued rubber wheel, proves human error is a symptom. Identifies four traps—counterfactuals, normative language, mechanistic reasoning, and blaming—and prescribes concrete practices: run a facilitated post-incident review with interviews, ask “what factored into that decision,” record how recovery succeeded, and separate planning from analysis.
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chapters (18)
- 0:00Introduction
- 2:12A story about a plane
- 4:23Structure
- 5:15Why
- 6:08Complex Systems
- 8:34Two Things to Think About
- 9:43Language Matters
- 10:53Alfonzo Panis
- 11:55The B17
- 13:39Cockpit Design
- 14:11Human Error
- 15:23Counterfactual Reasoning
- 17:20Normative Language
- 22:17Post Incident Review
- 25:14Asking Better Questions
- 27:24Critical Insights
- 28:52Review Planning
- 30:33Summary
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