Recipes and Intent

Ten years ago, while stationed on a small Portuguese island, I learned to make bread. I’d find a recipe, follow the directions, mix the ingredients, and await the results.

If I wanted a different bread, I couldn’t simply think harder, read more about bread, or talk about it.

I had to use a different recipe.

In EHS, many organizations bake bread too. They call it “incident investigation”, or even “site inspection”.

And they have the best of intentions. They’ve read the latest studies. Hired consultants on the newest behavior-based science and root cause analysis. And joined the most prestigious EHS associations.

Then they go back and use the same recipe.

Over and over.

Expecting different bread.


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