Root cause analysis. The five whys
The Chernobyl Accident (1986)
USS John McCain Collision (2017)
Finding the root cause of a failure is like finding the root cause of a success
A most extraordinary report
3: enclosed in a containment
Human error is not a cause, it is an effect.
If people are punished for being honest about what transpired, employees will soon learn that the personal costs to speaking up far outweigh the personal benefits. Improving the safety of a system is rooted in information.
|First Stories||Second Stories|
|Human error is seen as cause of failure||Human error is seen as the effect of systemic vulnerabilities deeper inside the organization|
|Saying what people should have done is a satisfying way to describe failure||Saying what people should have done doesn’t explain why it made sense for them to do what they did|
|Telling people to be more careful will make the problem go away||Only by constantly seeking out its vulnerabilities can organizations enhance safety|
How you act in a crisis will set the tone
Communication is crucial
Explain clearly what you look for
Try to get the best out of people
Consider listening to what an incident has to teach you. It's your job to figure out what that is.
John Allspaw, Incidents as we Imagine Them Versus How They Actually Are
Incidents will show the way
Accept it: there will be unknown unknowns
Try to understand and solve issues thoroughly
What can be done to avoid a repetition?