Much of the evidence heard by the Royal Commission was from people who didn't know what was happening - either because they were too junior to have all the information, or, if they were senior, too busy to have stopped and asked the question. Provoked by Dr Darren O'Donovan, in this episode we unpack practical steps that create organisations that can't look away. The discussion covers - capturing the right data, and sharing it routinely and publicly - risk as a frame for empowering people to push unwelcome information up - the challenges with record keeping for institutional continuity, including the lost art of capturing decisions Referenced in the episode: - The Checklist Manifesto by Atul Gawande, on building safety culture - The Squid Hunter by David Grann (Alison's giant squid article) Intro and further grabs from our special bonus episode interview with Dr Darren O'Donovan, Senior Lecturer at La Trobe Law School. Later grabs from: Mr Finn Pratt AO PSM and Commissioner Catherine Holmes, 10 November 2022, and Ms Serena Wilson and Mr Justin Greggery KC, 9 November 2022. Now for some appropriately bureaucratic disclaimers.... Those of us in the employ of the State Government speak in a strictly personal capacity, consistent with the Public Sector Code of Ethics that permits public servants to promote an outcome in relation to an issue of public interest - in this case, the betterment of the public service. Nothing we say should be taken as representing the views of the Government or our employers. While we have tried to be as thorough in our research as busy full time jobs and lives allow, we definitely don’t guarantee that we’ve got all the details right. If you want rigorous reporting on Robodebt, we recommend the work of Rick Morton at the Saturday Paper, Chris Knaus and Luke Henriques-Gomes at the Guardian, Ben Eltham at Crikey, Julian Bajkowski at The Mandarin, and of course, the Robodebt Royal Commission itself. The first eight episodes were recorded before the Royal Commission launched its report and so don’t benefit from the great wisdom of Commissioner Holmes. Please feel free to email us corrections, episode suggestions, or anything else, at [email protected]. Thanks to PanPot audio for our intro and outro music. 'Til next time!