Jens Rasmussen

So let's explore that in a bit more detail as we come to some parts here.

So flexibility is important, and I sort of, again, link this to a really important scholar called Jens Rasmussen, who you might have heard of.

He was one of the fathers of sort of safety to and resilience engineering in a way, because he started to push us to think differently about what creates safety.

The traditional way of thinking about what creates safety is pushing operations away from the unsafe kind of zone and putting restrictions and applying constraints that lock the uncertainty down.

Because one of the things, Musa, that's very interesting to me is that when we started this discussion, With Tony Machara and some of the info guys, James Reason, the original Clambake clan.

I mean, all kind of the people, Jens Rasmussen, all those guys were a part of this discussion a long time ago.

And when we started this discussion, it's really funny because we started thinking we could manage human error.

That this was about management of error.

Cause is constructed, not discovered.

Decades ago, Jens Rasmussen, one of the most famous researchers in safety science, made an observation that has been confirmed repeatedly since.

When we explain an accident in causal terms, we are not reading the structure of reality.

We are matching the flow of events against a set of mental models or experiences that feel familiar to us.

It was to ask the bigger questions.

How did the system fail? What decisions, pressures, and organizational influences lined up to create the conditions for the incident? And most importantly, what can we learn? In this episode, the students have examined one of aviation's most significant accidents, American Airlines Flight 191, using Rasmussen's AXIMAP framework.

Their discussion demonstrates exactly the kind of systems thinking that sits at the heart of human factors.

Now, I know most of our Hema Factors Economic Society listeners are already familiar with these tools.

Nah, I'm just kidding.

It's 1997, and Carlo would know this.

And this guy, Jens Rasmussen, is investigating accidents in transportation.

He's a real nerd, and he starts asking really good questions and making some really good points, including... to design safer systems, we still witness severe large-scale accidents.