22. Common themes:- Taking short cuts- Being „helpful‟- “Why don‟t we try…”- Commercial/time pressure- Lack of/ineffective trainingAll Failure to follow procedureIncreased likelihood of something going wrong
23. In a high-hazard environment, ANY andALL operations can be SAFETY-CRITICALSo how do we get this message over?
24. PROCEDURESWritten, clear, rehearsedCHECKLISTSAs an aide-memoire, not a box-tickingprocessTRAININGTo reinforce the message