Pre-Accident Investigations

Contents

List of Figures

List of Abbreviations

Foreword: A Context Setting Discussion

Preface

Acknowledgments

1 A Story of a Failure

2 Why Think about Failure at All, Let Alone Think “Differently” about Failure?

Case Study: The Titanic: A Story to Help You Rethink How You Think About Failure

3 Change the Way Your Organization Reacts to Failure

Pre-Accident Investigation Tool

Case Study: Aviation Accidents are the Unexpected Combination of Normal Aviation Variability

4 Workers Don’t Cause Failure, Workers Trigger Failure

5 Change is Better When You Manage Change—And Change Needs to be Managed

Case Study: Nine Senior Managers, a Million Different Opinions on How to Handle a Problem…and Nobody Willing to Change

6 Thinking about Where Failure Will ...