
The Safety of Work
Ep. 119: Should we ask about contributors rather than causes?
Apr 28, 2024
Exploring accident investigation techniques with a focus on systemic contributors over root causes. Critiquing traditional root cause analysis and emphasizing the importance of organizational pressures on safety incidents. Analyzing factors contributing to accidents through categorization and diagramming. Discussing organizational pressures and work adaptations in incident analysis. Reevaluating incident interpretations and investigative approaches in light of missed failure modes and learning from past events.
45:19
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Quick takeaways
- Focus on contributors over causes for better safety insights.
- Analyze systemic organizational pressures for understanding work adaptations.
Deep dives
Focus on Learning Breakdown Between Spacewalks
There was a breakdown in learning between the two spacewalks due to production pressure, essential tasks taking priority, and missed opportunities from not conducting detailed analysis after the initial spacewalk.
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