Root Cause

Safety Thought of the Week… be as inquisitive as a 5-year old

I used this humorous video to open my casual analysis training. Every parent has been there, but our kids’ curiosity is great. It’s how they LEARN. Sure, they may not understand all they are hearing (the same goes for adults in accident investigations), but that curiosity is what we need when leading a causal analysis…...

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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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Safety Thought of the Week… are worker behaviors the problem?

I know I made these mistakes in my early years. In the early 1990’s “Behavior Based Safety” was all the rage, and it had me “hook, line, and sinker.” Sometimes, I wish I was still in contact with some operators/maintenance tech who got the raw end of our (mostly mine) investigations and causal analysis so…...

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UK’s HSE “Adverse Events” publication (HSG245)

Many workplaces struggle with one of the most critical elements of any attempt to manage safety and health via a safety management system – Incident Investigations. From the struggles of getting personnel to REPORT incidents (including near misses) to management recognizing these reports are GIFTS handed to us! But what normally happens, is we get…...

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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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