Today’s paper, “Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss” by Katherine E. Walker et al, examines an incident wherein a NASA astronaut nearly drowned (asphyxiated) during an Extravehicular Activity (EVA 23) on the International Space Station due to spacesuit leakage. The paper introduces us to an innovative and efficient technique developed during Walker’s PhD research.
In this discussion, we reflect on the foundational elements of safety science and how organizations are tirelessly working to unearth better methods for analyzing and learning from safety incidents. We unpack the intricate findings of the investigation committee and discuss how root cause analysis can sometimes lead to the unintended consequence of adding more pressure within a system. A holistic understanding of how systems and individuals manage and adapt to these pressures may provide more meaningful insights for preventing future issues.
Wrapping up, our conversation turns to the merits of the SCAD technique, which champions the analysis of accidents as extensions of normal work. By examining the systemic organizational pressures that shape everyday work adaptations, we can better comprehend how deviations due to constant pressures may lead to incidents. We also critique current accident analysis techniques and emphasize the importance of design improvement recommendations.
Discussion Points:
- History and current state of accident investigation
- Systemic solutions in safety
- Traditional root cause analysis challenged by new perspectives
- NASA's 2013 EVA 23 space walk incident examined
- Organizational pressures and their impact on safety
- SCAD technique for accident analysis efficiency
- Shift from tracing causes to understanding work adaptations
- Emphasis on normal work analysis for accident prevention
- Critique of NASA's administrative processes in safety
- Cognitive biases and challenges in accident investigations
- Continuous evolution of safety practices
- Practical takeaways -how do you go beyond the immediate events to find broader systems and broader learnings?
- Canging language away from causes to talk about pressures and contributors
- The answer to our episode’s question is, “Yeah, it probably helps, but still doesn't fix the problem that we're facing with trying to get useful system changes out of investigations.”
Quotes:
“We've been doing formal investigations of accidents since the late 1700s early 1800s. Everyone, if they don't do anything else for safety, still gets involved in investigating if there's an incident that happens.” - Drew
“If you didn't have this emphasis on maximising crew time they would have been much more cautious about EVA 23” - Drew
“Saying that there's work pressure is not actually an explanation for accidents, because work pressure is normal, work pressure always exists.” - Drew
“One of the things that is absent from this technique through and they call it an accident analysis method is there is no commentary in the paper at all about how to design improvements and recommendations.” - David
Resources:
The Paper: NASA Near Miss
The Safety of Work Podcast
The Safety of Work on LinkedIn
Feedback@safetyofwork
The Safety of Work