The nature of oversight and improvement

Investigators believe that acting on incidents - and risks - is the ultimate purpose of safety oversight. The purpose of collecting and analysing incident reports is to act to use incidents to improve organisational 

Using incidents Applying resources and getting things done 

They may have trouble with making [safety] recommendations, as they are a purist rather than a pragmatist.. . Purism has to be tempered with pragmatism even when it comes to risk assessing these things. (Si3-8) 

It is a purely academic exercise unless you do something with it. So the question is, what are you doing with the risk, and how does that influence the organisation (Si6-5) 

This distinction drawn by investigators is essentially between analysis that attempts to produce a certain fact and analysis that allows them to effectively act. Their analytical efforts are always oriented to action, and risk analysis is a pragmatic process that is engaged in to achieve safety improvement  

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