Many organisations rely on their root cause analyses (RCA) to help learn about incidents, and, ideally, prevent incident reoccurrences. So the logic goes. But does the published evidence support RCA approaches as effective means for preventing incident reoccurrences? Today’s paper is Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J.… Continue reading Safe As podcast ep15: Root Cause Analyses (RCA) and incident prevention – do they ‘work’?
Tag: root cause analysis
Safe AF ep #3: Learning Teams vs Root Cause Analyses (+ transcript)
Safe AF pod ep #3 now live! How well can Learning Teams function against more traditional Root Cause Analysis techniques? What things do they focus on, what fixes result from the learning activities? Does one focus more on blame and individuals? Today we explore a paper by Robbins et al., 2021, comparing Learning Teams vs… Continue reading Safe AF ep #3: Learning Teams vs Root Cause Analyses (+ transcript)
The issues of ‘root causes’ and infinite regression (the endless search for the causes of causes)
A really interesting, but challenging, read about the ontological status of ‘root causes’ and more pointedly, the problem of infinite regression. The author also proposes some stop rules to help navigate infinite regression. I’ve previously posted articles critical of the status of ‘root causes’, who argue it is more a process of implicit or explicit… Continue reading The issues of ‘root causes’ and infinite regression (the endless search for the causes of causes)
“there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Extracts from Dekker’s work about the ontological and empirical shakiness of ‘root causes’. I’ve taken material from two versions of The Field Guide to Understanding Human Error (Investigations). In Dekker’s view: · “There is no ‘root’ cause” (or ‘root causes’) · Given the multiple angles and interactions in complex systems, you “can really construct “causes” from everywhere”… Continue reading “there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Root-Causal Factors: Uncovering the Hows & Whys of Incidents
This 2016 article from Fred Manuele explores some facets of causality in investigations. It’s based mainly on two key sources: Hollnagel’s 2004 ‘Barriers and accident prevention’ and Dekker’s 2006 ‘Field Guide to Understanding Human Error’. Won’t be much new for most but has some nice arguments from authors like Hollnagel, Dekker and Leveson. First he… Continue reading Root-Causal Factors: Uncovering the Hows & Whys of Incidents
SafetyInsights.org 