Post by Craig Tonks

For twelve years I’ve been trying to understand one morning on Adelaide’s South Eastern Freeway. I thought I understood it. I didn’t. This is the first essay in a series I’ve called Shaping Outcomes. Over the years, working across investigations, operations and safety, I’ve become less interested in asking what happened? I’m far more interested in asking… What conditions were quietly shaping this outcome long before anyone recognised there was a problem? This first essay reflects on a tragedy that has stayed with me for more than a decade and how my understanding of it has changed over time. I’d love to know whether it changes the way you think about investigations, leadership or operational systems.