leadership is actively suppressing, even punishing, learning and improvement, perpetuating quality and safety problems ii. high-trust culture 1. we are all lifelong learners who must take risks in our daily and practices can be used by the entire organization iii. ENABLING ORGANIZATIONAL LEARNING AND A SAFETY CULTURE 1. When we work within a complex system, by definition it is impossible for us to perfectly 2. Dr. Ron Westrum was one of the first to observe the importance of organizational culture on safety and performance. Dr. Westrum defined three types of culture: a. Pathological organizations are

as quickly, frequently, cheaply, and as soon as possible i. Institutionalize rituals to increase safety, continuous improvement, and learning ii. Create mechanism to rapidly spread learning throughout evolved beyond it b. ESTABLISH A JUST, LEARNING CULTURE i. Unjust responses to incidents 1. Impede safety 2. Promote fear over mindfulness 3. Create bureaucracy rather than carefulness 4. Cultivate secrecy and gather details of the failure from multiple perspectives2. Empower all engineers to improve safety by allowing them to give detailed accounts of their contributions to the failures 3. Enable and

necessarily evolve over its life cycle.” b. AN ARCHITECTURE THAT ENABLES PRODUCTIVITY, TESTABILITY, AND SAFETY i. Loosely-coupled ii. Well-defined interfaces that enforce how modules connect with each other