In Part One, we discussed a 2001 Harvard University study of hospital nursing teams that showed how the prevalence of first-order problem-solving (“fixing and forgetting”) rather than second-order problem-solving (“fixing and reporting”) prevents organizations from learning from their own operational issues. This fixing and forgetting approach leads, in turn, to the perpetuation of hazards by depriving organizations of the opportunity to devise effective solutions and/or safety barriers.1
Part One also analyzed a serious incident in 2022 involving a Cessna Citation 525 and an Embraer 170 that experienced a loss of separation due to erroneous altitude indications provided by the Cessna’s faulty pitot-static system — an occurrence that illustrates how inadequate problem-solving can preclude risk management and result in dangerous events. After discussing the factors that commonly lead to the adoption of first-order problem-solving, we w…
