Root cause analysis? You're doing it wrong
2 days ago
- #root-cause
- #accident-analysis
- #systems-theory
- Root cause analysis is often based on simplified models, leading to insufficient understanding.
- Deeper accident analysis allows learning more from fewer accidents by identifying multiple contributing factors.
- Preventing hazardous system states is crucial since environmental conditions cannot be controlled.
- Accidents occur when a system in a hazardous state meets unfavorable environmental conditions.
- Controllers maintain system constraints through technical and social control actions at different levels.
- Human error should be the starting point, not the conclusion, of accident investigations.
- Systems must support operators in building accurate mental models for dynamic responses.
- Safety is a dynamic control problem, not just failure prevention.
- Traditional causality models like chain of events or Swiss cheese are inadequate for complex systems.
- Systems theory focuses on emergent properties and interactions over time for better analysis.