Chapter 5

Ladder of inference

- Learn to get back to facts and use our beliefs and experience to positively effect outcomes,
rather than allowing it to narrow our field of judgement
- Observe > data > meaning > assumptions > conclusion > beliefs > actions
- Reflexive loop (go back down ladder to check on beliefs and assumption)

Mental model

- Explanation of the thinking process

- Helps to shape behaviour and set approach to solving problems
- Determines what we see and do not see
- Determines how we take actions
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Fifth discipline (system thinking)

- Re-create ourselves
- Do things we were never able to do before
- Re-perceive our relationship to it
- Extend our capacity to create and to be part of it

Personal mastery

- Organization learns only through individuals who learn

- Learning to generate and sustain CREATIVE TENSIONS in our live

Team learning

- Process of aligning and developing the capacity of a team to achieve results that members
desired

Shared vision

- Provides rudder to keep learning process on course when stresses develop

- A vision that many people are committed to and it reflects their own personal vision

Creative tension

- What do we want?
- What do we have?
- What actions do we have to take?
- What do we have to keep, build or destroy to get what we want?
Iceberg analogy

- React to events
- Respond to patterns
- Design structures
- To get to root of any issue, we should uncover underlying structures which forms the patterns
and events

Events

- Occurrence at some point in time

- Solutions to events are short-lived (address issues at structure that caused event)

Patterns

- Changes of events over time

- Allows us to understand systemic structure that caused them

Structure

- The way systems and components are interrelated

- Give rise to events and patterns

Swiss cheese model

- Accidents caused by series of errors

- Accidents are caused when “holes” in all the defences are aligned
Human factors

- The study of human capabilities and limitations in workplace

- Human error (1. Sources of error 2. Types of error)
- Managing human factors (1. Error management 2. Human resource management)
- Optimizing human and system relationship improves safety, quality and efficiency

Need to focus on human factor

- Enhance awareness
- Acquire human factor skills (communication, effective teamwork, task management)
- Positive impact on safety and efficiency
- Encourage positive attitude towards safety while discouraging unsafe behaviour

Attributes of human factors

- Human physiology
- Anthropometrics
- Psychology (provides source of background knowledge)
- Workplace design
- Environmental conditions
- Human-machine interface

Error chain

- Involves a series of human factor problems which forms an error chain

- Accident happens when one of the chains breaks