I read through Atomic Accidents by James A. Mahaffey, and kept highlighting bits of blame and narrative structure that irked me the wrong way and seemed to represent a convenient stopping point for the report rather than a useful one, and left us without critical lessons.

I ended up having so many small feelings about it that it was too long to fit a goodreads review and I had to write a whole blog post about it:

https://ferd.ca/notes/atomic-accidents-and-uneven-blame.html

@mononcqc Thanks for posting this. On my reading list now. "Command and Control: Nuclear Weapons, the Damascus Accident, and the Illusion of Safety" is a great book too.

Are you familiar with Todd Conklin's work? He worked at Los Alamos. He and his colleagues have been pushing changes to the safety industry. They're less about worker blame and focus more on systems, processes, and culture. His Pre-Accident Safety Podcast is fantastic.

Sample of his thinking: https://www.youtube.com/watch?v=lWPJzGtmiOQ

@jameshubbard I'm familiar with the name and I've read Pre-Accident Investigations, but I haven't gone through a lot more of his material otherwise.

I currently have "Command and Control" on my reading list, but it's a bit further down than The Limits of Safety by Scott D. Sagan, which seems to hit a similar spot (it specifically digs into the history of non-accidents in nuclear weapons by applying HRO theory and Reason's normal accident theory, and uncovering stuff in archives).

I really enjoyed Atomic Accidents, and this writeup looking at it through an LFI lens Is also great.

RE: https://hachyderm.io/@mononcqc/112892753671661329