ACCIDENT REPORTS MAY NOT TELL US EVERYTHING WE NEED TO KNOW

摘要

Accident reports often miss some of the lessons that can be learned. We should try to read between the lines and look for the recommendations that might have been made but, for various reasons, were not. They may not have been foreseen, or there may have been reasons for deliberately excluding them, such as reluctance to embarrass colleagues or to admit that a similar accident had occurred before, but had been forgotten. Examples are described.