The seductive logic of the search for the “root cause”

A recent article by Nancy Leveson and Sidney Dekker discusses the problems associated with searching for the “root cause” of accidents.

The article argues that trying to identify, and eliminate, the “root cause” of accidents leads us to focus on symptoms, rather than the underlying causes of accidents.   For example, in the outdoor context the symptom might be “participants doing the wrong thing”, while the underlying causes might be unclear instructions, design of the activity, and communication with the school about behavioural problems.

There’s also a good discussion of the common biases associated with understanding accidents, and how a systems thinking approach (like UPLOADS) can help overcome these biases.

The article was written for the Chemical Processing industry, but is useful for anyone interested in learning more from accidents.

Click here to read the full article.

Posted in Systems thinking, UPLOADS
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