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There is no root cause

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 …

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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. …

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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 …

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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 …

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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 …

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