Systems Thinking, Complexity, and Root Cause
I’m getting so very tired of safety/accident researchers claiming that root cause analysis is an invalid, blame-focused practice that ignores systems and complexity. Most root...
Tagged: philosophy
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...
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...
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...
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?...
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...
Phases of Root Cause Analysis
Root Cause Analysis (RCA) is generally conducted in several phases. I’ve seen some methodologies that break down the RCA process into as many as a...
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...
Four Ignoble Truths
Before you decide how to fix a problem, you should probably seek first to understand it… perhaps with a root cause analysis. That is, unless...