Politician Calls for Better Investigations
This is the case of a ferry accident where a local rep was not happy with the outcome of the investigation. The only corrective action mentioned was discipline of the workers (sound familiar?)
Here is a quote from the rep:
“Why didn’t a system with multiple redundancies catch the human error?”
I usually don’t like mixing politics with investigations, but in this case, the gentleman seems to be asking some good, hard questions. These are the kinds of questions you should ask during a good root cause analysis. Unfortunately, many organizations do not have the experience or commitment to do that. Those that are committed and want to leverage the use of an expert system use TapRooT®.
Here is the story: