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Incident Analysis: How Learning is Different Than Fixing

简介

Most post-incident review documents are written to be filed, not written to be read.

This slide deck is awesome and well worth the read.

正文

I presented this at the excellent AllTheTalks Conference during the COVID-19 pandemic. :/

What does it mean to actually "learn" from an incident?

This talk will describe what we can do differently in the industry on this front, based on foundational methods from Cognitive Systems Engineering, Human Factors, and Resilience Engineering.

          April 15, 2020