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 […]
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 […]