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 …

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 …

Like a Rhizome Cowboy

Like a Rhizome Cowboy For those who know much about the philosophy of Gilles Deleuze they will know that a central part of his philosophy is the idea of a Rhizome. A rhizome is a tangled web of knotted stems (https://en.wikipedia.org/wiki/Rhizome) hidden below the surface. The rhizome is the perfect metaphor for Deleuzian philosophy but …

Just Get to the Bottom of it

Just Get to the Bottom of it….. Republished by request.......... An incident occurs at work, the well entrenched procedures quickly kick into play - first aid provided, forms filled in, reports to management, find the cause (sometimes causes), change operating procedures (they must have been wrong), issue Safety Alert and conduct Toolbox Talk, include information …

Critical Thinking and Questioning in Safety

Critical Thinking and Questioning in Safety Great to read a piece on the Safety Differently site that situates systems within a social and societal context (Thinking Differently about incident investigations). One of the strange things about the tradition of safety is its maintenance of the myth of objectivity, particularly in investigations. Benner’s piece helps us …