root cause Archives - Safety Risk .net

March 28, 2019March 28, 2019

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… Read the rest

August 18, 2018August 18, 2018

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… Read the rest

April 29, 2017April 29, 2017

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… Read the rest

November 5, 2016July 2, 2018

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… Read the rest

June 30, 2016April 16, 2017

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… Read the rest