Why learning has NOT been our first, best tool
The challenge is to create an environment for event communication that is fixated on operational learning and then allow this learning communication to happen. That open and non-personal learning environment is essential to understanding the story of how what happened, happened. This conversation is about learning the problem, not about fixing the problem. Fixing is a retrospective response to an accident in retrospect. Fixing has to happen after learning, as a result of learning. Fixing can only occur after learning. Fixing that takes place before learning is a not fixing. Some big events have limited learning. Some small events are so information rich that the learning seemingly never stops. If safety professionals as a leader find the event interesting, it is probably kind of interesting and warrants some learning time.