THE WEEKLY
REFLEKTION
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The Weekly Reflektion 52/2023
Many companies are making the transition from ‘Human Error’ to ‘Human Performance’ in the way they investigate incidents and accidents and how they improve their performance. The ‘Human Error’ approach was based on the identification of what went wrong, who made the mistakes and led to actions to correct mistakes to prevent recurrence. The investigations most often did not get to the root of […]
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The Weekly Reflektion 22/2023
The legal system throws up some interesting examples of assigning blame and finding people negligent. Sometimes the concept of ‘beyond reasonable doubt’ doesn’t seem to be as important as finding a person(s) and administering justice. What is the legal system trying to achieve in its pursuit of determining negligence? In last week reflektion (week 21/2023) we asked the question ‘Is the […]
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The Weekly Reflektion 21/2023
Whan a Major Accident occurs there is often a public outcry and there follows a demand to find the person/people responsible. The public want punishment for these people for not doing their duty, perhaps a tendency towards an ‘eye for an eye’, ‘tooth for a tooth’ mentality that serves for justice in the minds of many. The major accident itself is normally investigated by a team of […]
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The Weekly Reflektion 01/2023
Systemic failures in the Norwegian Navy, on the Sola TS and Fedje Vessel Traffic Service were causes of this collision. Should we put the blame on human error or address the systemic failures? This is the third Reflektion regarding the collision between the Sola TS oil tanker and the Norwegian Navy frigate Helge Ingstad. The […]
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The Weekly Reflektion 52/2022
Labour shortages led to the bridge crew of the Helge Ingstad being less experienced than was the norm, but the job had not got any easier. Were the bridge crew on Helge Ingstad negligent, or did the Norwegian Navy set them up to fail? This is the second Reflektion focussed on the incident on 8th November […]
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