Re: Ford/Firestone and Concord

["bob" <bob.adsett@lineone.net>]

Lee

You probably could not find a better example than the recent Concord 
disaster where the failure of one component lead to catastrophic results for
those on the Air France jet.
I must admit to being quite surprised at the lack of comment about the
demise of Concord and the implications of systems thinking and how this
could aid a better understanding of what are the first steps that should be
taken to remedy the tyre problem.

Interestingly there have been a number of TV and radio programmes in the UK
in the past week of so exploring failing in the medical field. There is a
raising of awareness of the need for a systems understanding if we are to
create an environment for medical professionals to become more open about
the mistakes that they make. Only by developing a better framework for
raising problems and discussing what went wrong will we avoid others falling
in to the same procedural  pit-falls in the future. There were some
frightening statistics about the level of medical 'accidents' that have been
taking place in the US and I am sure that if we could only get to the
information the same will be found to be true of the UK.

One pleasing response from the debate has been a willingness to recognise
that when things go wrong we need to look to the cause of the problem rather
than try and find SOMEONE to blame. Maybe we are starting to see a readiness
to accept that we will only get improvement if we start problem solving and
stop blaming .
I only hope that the media can be encouraged to realise that the public good
is better served by changing the system, rather than getting cheap copy and
sensationalism that drives honesty and openness underground. Which will only
increase the likelihood of a similar occurrence happening again.

bob

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Bob Adsett
Bingley, Yorkshire, UK

Tel.   +44 (0) 1274 77 95 02
Mobile +44 (0) 7980 85 22 34
e-Mail bob.adsett@lineone.net