The Failure of Hindsight

Abstract

One of the most disturbing features of man‐made disasters is that often the cause has been known beforehand but little or nothing has been done to prevent the occurrence or often re‐occurrence. Examines the failure to implement the lessons from previous experience.

The dangers of heparin flushes

“…Such events demonstrate that if the circumstances surrounding an unwanted event are allowed to replicate themselves then it is highly likely that another similar unwanted event will take place regardless of geographical location or time—that is, an “isomorphic failure” can take place 15. There seems to be no compelling medical evidence or advice from any quarter to suggest that a “heparin flush” is any more effective in keeping intravenous peripheral lines patent than a saline solution.…”

Managerial and non-technical factors in the development of human-created disasters: A review and research agenda

“…The assumption that organizations are likely not only to seek to learn from accidents (their own and those of other organizations) but also to seek to implement remedies that would help to avoid such accidents has long been challenged (Fischhoff, 1975;Toft, 1990;Turner and Pidgeon, 1997;Waring and Glendon, 1998). If an organization experiences difficulty in learning from its own mistakes and accidents, it is perhaps unsurprising that it would not learn readily from mistakes and accidents in other organizations.…”

“…Le Coze and Dechy (2005), Toft (1990), Toft and Reynolds (1997), Turner (1992) and Turner and Pidgeon (1997) discussed the contribution of organizational learning, hindsight and foresight to understanding human-made disasters. The assumption that organizations are likely not only to seek to learn from accidents (their own and those of other organizations) but also to seek to implement remedies that would help to avoid such accidents has long been challenged (Fischhoff, 1975;Toft, 1990;Turner and Pidgeon, 1997;Waring and Glendon, 1998).…”

Framing the MH17 Disaster – More Heat Than Light?

“…This dynamic quality of system operation, the balancing of demands for production against the possibility of incipient failure is unavoidable. Toft's (1992) isomorphic learning prism, the KAL007 and IR655 shootdowns created a space for active learning -The Flexible Use of Airspace concept, which holds that "airspace should no longer be designated as military or civil airspace, but should be considered as one continuum" (Eurocontrol, 2014) -The shareholder agenda (maximise profit and dividend) -The passenger agenda (generally to pay as little as possible for a ticket) -The conscious post-1970s engineering of a liberalised and highly competitive global aviation system (Zellner & Rothman, 1992;Crandall, 2008). Robert Crandall, CEO of American Airlines, argued that aviation is "intensely, vigorously, bitterly, savagely competitive" (Crandall as cited in Sherman & Chaganti, 1998, p. 93 Commercial aviation is plagued by upswing and downswing (Petzinger, 1995) -The aviation system's cost-reduction culture.…”

“…Had the aviation system internalised the lessons of past incidents and accidents, it probably would not have allowed flights through contested airspace. Systems-thinking, which finds expression in Toft's theory of passive and active learning (Toft, 1992;Toft & Reynolds, 1997), encourages us to think of past events not as footnotes in the historical record but as potentially life-saving learning opportunities. Passive learning describes a situation where there is knowledge but no remediation.…”