Interesting article dispelling some “root cause” myths. First published here: https://www.kitchensoap.com/2012/02/10/each-necessary-but-only-jointly-sufficient/ Each necessary, but only jointly sufficient I thought it might be worth digging in a bit deeper on something that I mentioned in the Advanced Postmortem Fu talk I gave at last year’s Velocity conference. For complex socio-technical systems (web engineering and operations) there […]
Investigation
River of tears
River of tears On 25th October 2016 a tragic incident on the Thunder River Rapids Ride at the Ardent Leisure Dreamworld amusement park near Queensland’s Gold Coast, claimed the lives of four people. A circular raft containing six passengers collided with an empty vessel and flipped upwards and capsized as it approached the disembarking dock. […]
Please share our posts
There’s a Hole in Your Investigation.
There’s a Hole in Your Investigation. Any fatality is sad news for family and loved ones of those who have died. It is even more sad when there are no definitive answers for cause. Many who die working alone cannot be interviewed, one can never know the root cause. Root cause is the concoction that […]
Please share our posts
The SEEK Investigations Donut
The SEEK Investigations Donut As a part of the SEEK Investigations Workshop (http://cllr.com.au/product/seek-the-social-psyvhology-of-event-investigations-unit-2/ ) we explore what is missing from contemporary and popular investigations methods. We use the idea of a donut to imagine what is missing from the centre, and use the donut metaphor to explain the gap in thinking between common investigations models […]
Please share our posts
Investigations and Heuristics
Investigations and Heuristics One of the traps investigators fall into is thinking that people are the sum of inputs and outputs, that the behaviourist myth is true. Decision making in complex and far more sophisticated than the naïve proposals of the behaviourist worldview. Rewards and punishments are not primarily the cause of behaviours. There are […]
Please share our posts
Investigations and Power
Investigations and Power In the previous blog I raised concerns about the nature of Investigations and truth telling, and the affect of culture on one’s capability to extract the truth in investigations (https://safetyrisk.net/investigations-and-truth-telling/ ). In this blog I wish to raise the important issue of power in the process of investigating. One of the benefits […]
Please share our posts
Investigations and Truth Telling
Investigations and Truth Telling One of the essentials to undertaking an investigation is truth telling. However, there are many dynamics in organizational culture that mitigate against truth telling. ‘Honesty may be the best policy’ but ‘blame is the big game’ when it comes to safety investigations, especially in zero organizations. It is not possible to […]
Please share our posts
SEEK Investigations Workshop
SEEK Investigations Workshop 5,6,7 July Canberra The next SEEK Investigations Workshop is in Canberra on 5-7 July at the Balcony Room, Tuggeranong Community Centre, Canberra. This is a great opportunity to experience a new and holistic way of investigations in the framework of the Social Psychology of Risk. What SEEK Investigations offer is an insight […]
Please share our posts
20 Cognitive Biases That Affect Risk Decision Making
20 Cognitive Biases That Affect Risk Decision Making Republished by request Thanks to Rob Long for sharing this – originally published here on Business Insider. Ever wondered why your decisions, risk assessments and incident investigations are not as objective as you may think? Rob Long defines cognitive bias (Here) as “a pattern of deviation in […]
Please share our posts
Don’t Let Evidence Get in the Way of Safety
Don’t Let Evidence Get in the Way of Safety When it comes to faith-belief, evidence rarely works. This is the primary discovery of Festinger et. al. in their study of Cognitive Dissonance. You can download When Prophecy Fails here The idea that people will make a ‘paradigm shift’ (Kuhn – The Structure of Scientific Revolutions) […]
