Topic

incidents

A collection of 5 issues

5 reasons why analysing barrier failures is better than 5-why

I hope you'll forgive me, but I don't really like 5-why. It's a decent methodology, but I think there are better options. Instead, we can use barrier-based incident analysis methods. Why is this better? Well, here are 5 reasons why I think analysing barrier failures is better than 5-why.

Barrier states

A barrier can have different states in an incident, mostly divided into four types: 1) Missing barriers 2) Failed barriers 3) Inadequate barriers and 4) Effective barriers. There are considerable differences in interpretation of these states, and when one or the other should be used. Here I'd like to give

30 years after Bhopal

In the media today you can read various accounts on Bhopal, exactly 30 years after the disaster. This video makes you think about how organisations often fail to deal with long term consequences of accidents. Often they already struggle to effectively implement corrective measures directly after an incident analysis is

Human error is like gravity

There are still incidents that get summarised to 'it was caused by human error.' This isn't useful. It'll be difficult to find an incident that doesn't include human error somehow. It's problematic because talking about the human condition as a whole is unlikely to get fixed anytime soon. Let

The root cause fallacy

After an incident has occurred, most investigations will try to find the root cause on a system or management level. To find the underlying reasons for an incident, instead of focusing on the more superficial ones. An important reason for doing this is the assumption that by fixing a single