Ep.39 Do accident investigations actually find the root causes?

To frame our chat, we reference the papers, Our Current Approach to Root Cause Analysis and What-You-Look-for-is-What-You-Find.

Determining root causes of accidents. Why investigations are social processes. An explainer on editorials. What “process change” really means. Applying the Swiss Cheese Model. Confirmation bias in research. Only finding what you can fix. The difference between internal and external investigations. Practical takeaways from the studies.

Quotes:

“What they suggested was that we should always have a very strong evaluation process around any corrective action to test and check whether it actually addresses the things that we’re trying to address.”

“To really understand how the investigation has happened, you’ve got to talk to the investigators as they’re doing the investigation…”

“I can’t imagine a safety person taking to the board a recommendation that they weren’t sure themselves, they could fix.”