Executive action -- Dealing with the root cause -- Operator error -- the bad apples -- Holding to account -- Why things break -- Who's to blame? -- Trade-offs -- Reliable errors (or reliably error-prone) -- The second victim -- The downside of blame -- Paradigm shift -- Executive support -- Complex, adaptive systems -- The learning review -- The timeline -- The town hall -- The learning review framework
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"IT veteran Dave Zweiback describes an incident that threatens the very existence of a large financial institution, and the counterintuitive steps its leadership took to stop the downward spiral. Their novel approach is grounded in proven concepts from complexity science, resilience engineering, human factors, cognitive science, and organizational psychology. It allows us to identify the underlying conditions for failure, and make our systems (and organizations) safer and more resilient."--Page 4 of cover