2018 NSC Congress & Expo

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39 - Beyond Root Cause – A New View of Accident Investigations "JSE" (Room 381C)

Following a failure event, such as an accident, we all realize the importance and value of a thorough and effective investigation process. Despite this, the overwhelming majority of investigation techniques used by the profession are based on faulty assumptions and inadequate methods. As was stated in a recent publication, our methods are flawed. In this session, we’ll review some of the pitfalls inherent in common investigation approaches. These include misunderstanding the purpose of accident investigations, searching for the mythical “root cause,” using a “find and fix” mindset, and looking for blame. These pitfalls make it more difficult for us to learn and improve after a failure. We’ll explore more productive approaches and assumptions so we can stop looking for a root cause and start learning how to increase safety, learning and resilience in our organizations.