Pendulum Shifts, Context, Error, and Personal Accountability.

摘要

This paper describes a series of tools that were developed to achieve a balance in understanding LOWs and the human component of events (including accountability) as the INL continues its shift to a learning culture where people report, are accountable and interested in making a positive difference - and want to report because information is handled correctly and the result benefits both the reporting individual and the organization. We present our model for understanding these interrelationships; the initiatives that were undertaken to improve overall performance.