Tag: stpa

  • Learning More from Accidents

    Learning More from Accidents

    When accidents happen, there’s a seductive call to look for a root cause – that is, a chain of events without which, the accident would not have happened.  In hindsight, root causes are apparently easy to identify; one works backwards from the accident, identifying causal threads until reaching the “root cause.”  It’s simple, and it’s generally wrong.…