March 28, 2006 | Mark Paradies

What is a “cause” of a near-miss?

Boeing717

Kevin McManus sent me this link:

http://www.usatoday.com/news/washington/2006-03-26-chicago-takeoffs_x.htm

The article mentions “cause” several times. Causes mentioned include:

– air traffic controller error

– pilot error

– errant vehicle

Are these really causes or are they symptoms?

In TapRooT(R), these causes would be problems (called causal factors) that would be analyzed to find their root causes.

Even the specific root causes for each causal factor could be analyzed even further to look for generic (systemic) causes.

This in-depth analysis gets the investigator to a level of understanding that makes the development of effective corrective actions much easier (and more reliable).

I know that reporters aren’t trained in root cause analysis and use terms like “cause” loosely, but those who investigate accidents, incidents, and near-misses and use the information they gain to attempt to improve performance should have a systematic process for root cause analysis and then use terms like “cause” carefully so that management and the general public aren’t misled into believing that we have finished an investigation when we find a human error.

For information about TapRooT(R) see:

http://www.taproot.com/about.php

To get more information about TapRooT(R) Training see:

http://www.taproot.com/courses.php

Boeing737

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Root Cause Analysis
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