ABSTRACT
Managers, who acknowledge the pervasiveness of human fallibility, accept that their systems are not inherently safe. Managers must be intentional and relentless in discovering and correcting weaknesses (1) in the behavior choices of people that tend to drift from expectation and (2) in the accumulation of unsafe conditions and ineffective defenses that left unchecked would result in more frequent and severe events. The latter half of the chapter focuses on discovery—learning methods for detecting system weaknesses and vulnerabilities. The chapter concludes by describing the key elements of an effective management accountability tool—the Corrective Action / Preventive Action (CA/PA) process.
