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Mining for Root Causes

Tom Geraghty · Safety & Human Error, Interpersonal Practice

A newsletter on root cause analysis, five whys, and blameless post-mortems. Draws on John Allspaw to show why 'root cause' is a fiction that forecloses investigation — and how the conditions for honest inquiry must be established before the incident, not during it.

Connected concepts (5)

• Behind Human Error: Cognitive Systems, Computers, and Hindsight (paper)
• How Complex Systems Fail: Being a Short Treatise on the Nature of Failure, How Failure is Evaluated, How Failure is Attributed to Proximate Cause, and the Resulting New Understanding of Patient Safety (paper)
• Blametropism
• HOP
• Learning from Incidents