What’s wrong with Root Cause Analysis
A car skids while cornering at a certain point, turns turtle, and bursts into flames. From the car-driver’s point of view the cause of the accident was cornering too fast, and the lesson is that one must drive more carefully. From the county surveyor’s point of view, the cause was a defective road surface, and […]
Stages of Investigation
Oscar Wilde once said, “The truth is rarely pure and never simple.” And so accident reports eventually settle at giving people a meaning that appeals to them and maintaining social and political order. In walking the delicate balance between truth and fantasy, some tend to do a better job than others. Here’s a framework to […]
Is root cause analysis much different from witch-hunt?
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 […]
Scapegoating 🐐 : the bloodline of every culture
Every culture is held together by myths, rituals and symbols. The myth is the story; the symbol is that one element the story can be reduced to; and the ritual is how the myth is performed. There it is the myth of free markets; the symbol of Capitalism and the ritual of scapegoating – all […]
Are you surrounded by emojis?
I just came off a conversation with a very wise person from Ireland. Alan works in the fishing industry and travels extensively around the globe. Someone from the Ugandan fishing community shared this picture with Alan. Alan then reshared the picture with one of his friends in the village and Patrick’s immediate reaction was, […]