For the last six years I have been conducting several workshops on Learning from Accidents, and I’ve noticed all sorts of questions. Here’s one from a ship manager who caught me as I was finishing a session on the Costa Concordia accident.
“Tell me honestly, okay”, he said, “was a breath analysis test done on this captain just after the accident?”
After spending an entire day discussing the accident, I wondered what this person was trying to get to?
When someone is dead or injured, it is natural to look for a cause. But not any kind of cause. The cause should be easy to relate with, quick to resolve and dressed up as an act of moral wrongdoing. Once the cause is found, it has the power to bring an entire community together and distance them from those involved in the accident. When people come to know about the cause, their first reaction should be – ‘I would have never done that.’
Is root cause analysis any different from witch-hunt?
In his book Witchcraft, Oracles and Magic among the Azande, Evans-Pritchard explores how the Azande community from South Sudan locate meaning in human suffering.
A myth goes around within the Azande community that when a child gets sick, it could be because of contaminated food, adulterated water or a viral infection. But for the Azande, this kind of reasoning does not explain human suffering. Instead, they believe that suffering is the result of witchcraft transferred from someone close to the sufferer – someone whom they may have offended or cheated in the past. Bad luck follows. One way of putting an end to suffering is to find someone who is not liked by the members of the community, tie a rope around their neck and drag them through the fields. The cause of the suffering is found not so much in sophisticated reasoning but in convenient explanations.
We hear every now and then that we should abandon root cause and try a different method. But is root cause the problem?
When we give up on critical thinking and replace it with convenient explanations, does it really matter what methods or tools we use?
When we turn science into an ideology, may be witch-craft offers a better way to investigate accidents? At least it is true to its intent.
