The presentation will introduce practical methods Richard has used to understand why events occurred and develop a report that management can use to make rational decisions on the “real” causes of events. The methodology uses the work of Sydney Decker and James Reason, with whom most experienced practitioners are familiar, and the concepts of cognitive investigation (Ron Fisher, Florida Atlantic University) to present the decisions and factors that led to an event.
The basic precepts of the methodology are aligned with these principles:
- People do what they THINK their boss wants them to do
- People do what they do because they think it is the right thing to do at the time
- Events don’t just happen – they are the result of good people placed in challenging situations
- Organizations and individual tend to underestimate the risk of an event occurring based on their past successes
- The people involved in the event have the best idea of why they did what they did and what they could do differently next time
- Unless you can make management understand these principles, you can’t expect them to make substantive change
This presentation will expend on the principles above and introduce the attendees to a methodology used to investigate events and provide management an understanding of why the event really occurred. Rather than a complex Root Cause or other formal cause analysis, which is still appropriate for some events, the methodology recommended in the presentation is a practical method that a new or experienced practitioner can use to engage all levels of the organization in the learning process.
Richard will provide the participants a method that helps identify how organizational weaknesses contributed to the event and the need to develop SMART corrective actions to prevent recurrence. Even when using formal cause analysis techniques, the engagement of the participants in an event can help to formulate simpler and more effective corrective actions. In many cases, addressing issues at the “learning opportunity” level will prevent more significant events.
