John

“There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.”1”
― Sidney Dekker, The Field Guide to Understanding 'Human Error'

“Not being able to find a cause is profoundly distressing; it creates anxiety because it implies a loss of control. The desire to find a cause is driven by fear.”
― Sidney Dekker, Just Culture: Balancing Safety and Accountability

“In accident investigation, as in most other human endeavours, we fall prey to the What-You-Look-For-Is-What-You-Find or WYLFIWYF principle. This is a simple recognition of the fact that assumptions about what we are going to see (What-You-Look-For), to a large extent will determine what we actually find (What-You-Find). (The principle is furthermore not limited to accident investigation, but applies to human perception and cognition in general.) In accident investigations, the guiding assumptions are sometimes explicit, for instance when they are given as a directive or objective.

Erik Hollnagel. The ETTO Principle: Efficiency-Thoroughness Trade-Off (Kindle Locations 998-1000). Kindle Edition.”
― Erik Hollnagel, The ETTO Principle: Efficiency-Thoroughness Trade-Off

“If professionals consider one thing “unjust,” it is often this: Split-second operational decisions that get evaluated, turned over, examined, picked apart, and analyzed for months—by people who were not there when the decision was taken, and whose daily work does not even involve such decisions.”
― Sidney Dekker, Just Culture: Balancing Safety and Accountability