Recently I attended my required annual course on "Risk Managment" to prevent 
disastrous accidents and events happening in society or in a work palce.  Risk 
Management assumes that TO  ERR  IS  HUMAN. Risk Management looks at SYSTEMS 
and how to reduce the risks and consequences of human error.  The best example 
of a Successful System that has studied and implemented Risk Management model 
is the Airline industry.  This has prevented and prevents many potential 
accidents every day.  And the best example of a Failure is the Titanic disaster.

Contrary to what people think, it is very rare that errors happen due to a 
single person's fault.  The mitigating factors to accidents, human failures and 
effects of errors of judgment are a combination of:

1. Latent conditions which predispose to the failures (any failure including 
sexual failures and pedophilia).  And 

2. Contributing factors which exacerbate the failure after it has occured.

In the past we have lived in a CULTURE  OF  BLAME and Pass the Buck. Of course 
we Goans excel at this as seen in the MANY MANY heated post on any issue.  

The new / modern way is to look at a JUST CULTURE.  This is NOT a 'blame-free 
culture'. By definition, JUST CULTURE examines errors as symptoms of a flawed 
system. Just Culture (approaches) provides a climate where people can discuss 
mistakes openly in order to find ways to PREVENT THEM from occurring.  This is 
totally differnt from the thrust of posts that we have been seeing on Goanet.  
Hope individuals who have serious problems with the current system - what ever 
that may be, may look into JUST CULTURE approaches (if necessary with an 
outside consultant) to solve the problems they encounter. 

So as I look at the discussion of failure of priests, among other things, it is 
the community that permits priests to be liberal / reformed that may also be at 
fault. 

Risk Management DICTUM, "The system produces the results it is designed to 
produce."
Regards, GL


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