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Welcome to my weblog. Root cause analysis and root cause thinking are my main topics, but I do occasionally write about general problem solving, accident investigation, organizations, safety, and nuclear energy. If you're more interested in my reading than my writing (I wouldn't blame you), check out my LibraryThing catalog. Website job - CCpops Cupcakes and Cake Pops I don't think of myself as much of a web designer, but I'm reasonably happy with a new site that I set up for a cupcake business: Cupcakes and cake pops in Toronto - CCpops. (I happen to have... More>>> Bill, 2011/03/26 04:25 Adverse Health Effects Reported for Wind Power in Ontario (April 23, 2009) According to the Canadian Press and ... More>>> Bill, 2009/04/23 09:26 RCA at the AntiSyphus Effect Kathleen DeFilippo over at The AntiSyphus Effect has written a very nice collection of 10 articles on root cause analysis. I especially like how the articles flow from a logical starting point to a logical conclusion... something I've never really both... More>>> Bill, 2007/03/03 11:14 Root Cause Analysis for Human Behaviours, Part 1 Root cause analysis can be characterized in many ways. Some refer to it as a tool for continuous improvement. Others call it a method for finding performance problems. Those at the receiving end, however, often view root cause analysis as just a repackaged version of "the blame game". W... More>>> Bill, 2006/10/30 07:46 Root Cause Analysis - Art or Science? There are many commonly held beliefs about root cause analysis that bother me. Perhaps the single most irksome to me is the statement "it's an art, not a science." I don't have anything against art, but I don't believe that this statement does justice to the practice of root cause analy... More>>> Bill, 2006/10/10 01:57 Rockin' New Human Performance Investigation Tool Most problems and accidents involve human activity at some point or other. Often, this activity is right at the point of occurrence, and people at the sharp end are usually operating under difficult or confusing circumstances. They make decisions and take actions that... More>>> Bill, 2006/03/24 01:16 Optimization Is Not The Goal Problems come in all shapes and sizes. I've been involved in all kinds of investigations, from those dealing with something as mundane a chronic lack of hot water in a shower facility, to something as critical as a software error that caused non-conservative miscalculations of reactor operati... More>>> Bill, 2006/03/12 23:36 Systematic Problem-Solving Sequence Problems happen all the time. How we choose to respond is a major factor in determining how badly we will be affected by any given problem. I would argue that a systematic response is best, and furthermore, I propose a 9-stage sequence as discussed in this article.If you are already f... More>>> Bill, 2006/02/14 22:42 Cross-Pollination #2 Root cause analysis has a fatal flaw -- if you can't convince people that change is necessary, they will not change. Too many beautiful reports fail to make even a miniscule change in the course that an organization has already set for itself. The most thoroughly researched root cause analysis i... More>>> Bill, 2005/11/14 15:19 Software as Root Cause Wired News has a nice article on what they consider to be the 10 worst software bugs of all time (so far). I knew about a few of these, notably the Therac-25 fatalities and the Ariane-5 self-destruction. However, at least th... More>>> Bill, 2005/11/08 12:15 Einstein, Root Cause Guru I've been seeing quotations from Albert Einstein in various places lately. Here are a dozen of my favourites that I feel apply to the practice of root cause problem solving. I've tried to present them in a particular order that I think helps create a coherent message. I hope you'll mark these wor... More>>> Bill, 2005/10/31 00:09 Business Process Management - Solution or Cause? I've been trying to find out more about Business Process Management lately. What I've seen over a few years of doing root cause analysis is that many important root causes are related to how we design, manage, and operate key processes. I'm not just talking about typical business processes, eithe... More>>> Bill, 2005/10/30 12:54 Older newsRoot Cause Checklists Cross-Pollination #1 Root Cause Analysis Resource List Root Cause Analysis for Complex Systems? Five-by-Five Whys Use of Cause Categories in Root Cause Analysis Establishment of The Corner Office Human Error Why-Trees Root Cause Tools Readiness to Investigate Root Cause Roundup - May 2005 Root Cause Analysis Software Demos Patterns of Response Interfaces and Contradictions Models in Root Cause Analysis Meaning of Root Cause, Part II Root Cause Analysis - Large or Small Events? Meaning of Root Cause, Part I Introduction to Root Cause Analysis Phases of Root Cause Analysis The Fortunate Near-Miss Event RCA Tool Comparison The BOGUS Test Airport Terminal Collapse Environmentalism - Scientists versus Activists Wind in Ontario Event Frequency and Severity A Little Bit May Be Good For You Four Ignoble Truths Revamped Site |
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