The Rootisserie check for doneness prior to consumption

Human Error

How many times have you read a news article about a major problem or incident, and seen Human Error in the headline? A quick search...

Why-Trees

One of the most widely-used root cause analysis tools is the why-tree, otherwise referred to as a cause tree, root cause tree, causal factor tree,...

Root Cause Tools

I’ve just posted (in June 2005) the first article in my (hopefully) continually evolving series on root cause analysis tools. This first article provides my...

Readiness to Investigate

How do you know if your organization is ready to investigate and analyze events? Being ready involves a lot more than just having a root...

Patterns of Response

Problems happen all the time. How we respond ought to be a function of the problem’s importance… but how do we decide what is important?...

Interfaces and Contradictions

DrPat reads a lot, and frequently writes about books on Paper Frigate. One recent blog entry caught my eye, a review of Beyond Engineering by...

Models in Root Cause Analysis

Models are representations of reality. They can be detailed or abstract, complex or simple, accurate or misleading. Whether we realize it or not, everything we...