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by dbenhur
2955 days ago
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Yes, root cause analysis and corrective action should only to be done with Cook's insights in mind. "Post-accident attribution to a ‘root cause’ is nearly always wrong."
"Post-accident remedies usually increase the coupling and complexity of the system. This increases the potential number of latent failures and also makes the detection and blocking of accident trajectories more difficult." How Complex Systems Fail is short but loaded with value; if you haven't read it, go do so now! |
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