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 […]
root cause
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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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 […]
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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 […]
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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 […]
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Is the Safety Function Focusing On the Wrong Things?
Out of Focus: Is the Safety Function Focusing On the Wrong Things? By Phil La Duke on his blog http://philladuke.wordpress.com/ Phil says: In this week’s post I identify three areas that the safety profession has been obsessing on, and ask the question have we been focused on the wrong things for the past 100 […]
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Free 5 Why PPT Presentation
Free 5 Whys PPT Presentation This excellent 5 Whys root cause PowerPoint Presentation was sent to us by Tiaan V. It takes the audience through the basic philosophies of 5 Whys and provides trainer notes, worked examples, group exercises, flow charts and some useful tools. Thanks Tiaan – you can download it here:
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Free Root Cause Mapping Template in Excel
Free Root Cause Mapping Template in Excel ThinkReliability have proven that Microsoft of Excel software is not only useful for for creating spread sheets, their free safety template proves that it’s also an excellent tool for capturing and displaying each element of a thorough 5 whys or root cause analysis. The template uses drawing tools […]
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5 Whys Root Cause Analysis
5 Whys Root Cause Analysis 5 Whys Examples and Training Resources The 5-Why approach is thought to have been created by Sakichi Toyoda (1867 – 1930), the founder of Toyota, as a simple way to begin any investigation with the aim of determining the “root cause”. Can be used to solve any simple problem including […]
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ACTOR + ACTION + TIME = EVENT
ACTOR + ACTION + TIME = EVENT A weird and wacky hypothesis from Doug Wakefield CPMSIA RSP(Aust.) – SSHE analyst & trainer at Safe Measure Pty. Ltd. – www.safemeasure.com.au You can also download Doug’s FREE OHS Manual Template HERE This formula (Actor + Action + Time = Event) is a philosophical, theoretical, proposal for the […]
