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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Accident Investigation as Social Process
- Accident investigations are social processes, not purely objective scientific inquiries.
- Some explanations are more useful than others, even without perfect agreement on causation.
Root Cause Analysis Shortcomings
- Root cause analysis often overlooks deeper systemic issues in favor of surface-level problems.
- Accident investigation quality varies greatly across organizations and industries.
Hypotheses vs. Corrective Actions
- Focus on active failures means treating symptoms, not underlying systemic issues.
- Investigations generate hypotheses, not corrective actions themselves.