The Safety of Work Ep.39 Do accident investigations actually find the root causes?
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Aug 9, 2020 The podcast explores the challenges of determining root causes in accident investigations, emphasizing the social aspect of the process. It discusses the importance of generating hypotheses and avoiding bias, as well as the need to address systemic issues. The limitations of current accident investigations and the flaws in the approach are also examined, proposing a new method focused on actionable recommendations and goal-setting.
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Focus on Systemic Change
- Most RCA recommendations focus on reinforcing existing practices, not systemic change.
- Prioritize changes that eliminate hazards or reduce likelihood, not just blaming individuals.
Investigator Interviews
- Real investigations are more complex than manuals or reports suggest.
- Talk to investigators during the process to understand their reasoning, not just the final product.
What You Find Is What You Fix
- Identified causes become problems to be fixed, limiting the scope of the investigation.
- Investigators often only find what they can fix due to organizational pressures.