Causal Analysis

Former Production Manager Pleads Guilty After Releasing Chemical Pollutants into the Cape Fear River (Active Failure vs Latent Organizational Failure)

This case is a classic example of how Latent Organizational Failures INFLUENCE the decision-making of workers (and middle managers). At the end of this press release, the DOJ admits that “Company management had informed some of its employees that if operations came to a halt, the company would suffer serious financial harm, potentially including dissolution.”…...

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Management Oversight and Risk Tree (MORT)

MORT was first developed in the USA to analyze the root causes and causal factors for incidents in the nuclear power and aviation industries, but it has now been applied in many industries. However, it seems to be a “lost art” these days! MORT is a pre-populated tree based on a model of an organization’s…...

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