Event
In common terms, an event is a finite change in the state of an entity during a finite timeframe. The variability of the factors –...
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For the term "event".
Root Cause Analysis – Large or Small Events?
Root Cause Analysis (RCA) can be applied to events of any size or significance. However, it’s usually applied to large events, i.e. those with serious...
The Fortunate Near-Miss Event
What do you consider to be an event worthy of investigation? Do you look only at events that had serious consequences, or do you consider...
Event Frequency and Severity
In 1931, HW Heinrich published his findings from a review of hundreds of thousands of safety incidents. His data showed that on average, for every 300...
HPT Treasures: Practical Situational Awareness
I posted about Situational Awareness at HPT Treasures today. What I didn’t say in that post was that I’ve experimented with a few different methods...
Re-Defining the Problem
Today, I saw a definition of Problem that I disliked VERY MUCH. Granted, this was in a Root Cause Analysis manual, so I expected much...
Unfinished Article: Optimization and Fragility
Have you ever found something you started writing but never finished? Here’s something I started in October 2014. I’ve just rediscovered it in July 2020....
Why Train? Why eLearning?
eLearning, to me, seems like an exciting new field that has barely been tapped and which has a wide open future. However, no matter how...
Top 5 Reasons for Failed Root Cause Analysis
Root cause analysis is one of the best ways to solve difficult or significant problems, but sometimes, root cause analysis efforts fail because the corrective actions weren’t...
Followup… System Focused Root Cause Analysis of Complexity
My previous post about root causes in complex systems, in retrospect, looks a little bit like a rant. That doesn’t bother me too much, really…...