In industry, all good safety programs and incident reviews utilize a root cause analysis (also used for quality issues) for exactly the issue you mention - making sure the group doesn't stop at the first "answer" they find. Several times the root cause is something quite distant from the actual event and also not intuitive. Given the severity of some incidents, plus that safety metrics are usually included in an individual's overall performance rating, everyone along the management line wants to ensure the analysis was thorough (assuming a good safety culture is established).
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From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**MED.CORNELL.EDU] On Behalf Of Ray Cook
Sent: Thursday, September 11, 2014 10:00 AM
Subject: Re: [DCHAS-L] Everything is Obvious
I will be interested to read this book, as I have taught a course worldwide emphasizing that obvious is our enemy during incident investigation. This is mainly because once we think we understand the problem, we no longer continue to investigate. Human nature leads us to make assumptions that are not accurate, and we end up implementing numerous corrective actions to solve it, when in fact, we usually tend to address the consequences and seldom address the underlying cause. Often one corrective action can solve the problem, but it is usually missed. It will be interesting to read this perspective.
Ray Cook, CIH, CSP
I Cor 1:18
Sent from my iPhone
> On Sep 11, 2014, at 8:49 AM, Ralph Stuart <rstuartcih**At_Symbol_Here**ME.COM> wrote:
> I went to a lecture yesterday by a Cornell visiting scholar from Microsoft who recently published a book entitled "Everything Is Obvious: *Once You Know the Answer". The lecture was about the limits of common sense as a strategy for making decisions. I think that a lot of the points he made were applicable to the recent string of chemical lab incidents we've been discussing, so I thought I would point out this as a potentially useful resource for the Chemical Health and Safety community.
> - Ralph
> Ralph Stuart, CIH
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