“Focusing on causes of accidents prevents effective learning.” This statement sounds it’s like going against safety fundamentals, but it’s based on safety science.
The idea of a root cause was developed in the early 1900s to troubleshoot simple mechanical systems. For example, a machine stopped working, we replaced the bearing, and it started working again. So, there was one failure point, one cause. Unfortunately, however, the same logic does not work very well to explain human and organizational behavior.
What people consider a cause reflects their mental model. For example, imagine we asked an engineer, a psychoanalyst, a management consultant, and a human-resources professional to explain why somebody didn’t follow a procedure. We would get four different answers reflecting their background and perspective.
When we try to use causes to explain behavior, it prevents us from going deeper. For example, what is the cause of a car accident? It’s easy to point to inattention or distraction, but it’s much more difficult to claim that the journey-planning system was a cause. Instead, if we asked what contributed to the incident, it’s much more acceptable to point out that the planning system allowed less time than needed for the journey and the delayed driver tried to get to the base before the dark.
In this video, I go through an example of a dropped object incident and show:
- How to identify error traps that affected the human error
- Who’s behind error traps—how to identify people who contributed indirectly to the incident
- How to identify organizational factors that influenced the incident
- Example of human factors analysis output for the incident
- How focusing on causes makes learning more difficult
- How to analyze why decisions made sense at the time—example of operational dilemma analysis
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