Tag: root cause

Organizational/Systemic Failure: Root Cause Analysis

June 21, 2022

The best case scenario for the Root Cause Analysis (RCA) approach to safety is when used to investigate a “close call”. In our experience, these are infrequently reported. Most commonly, an RCA is conducted when a fatality/injury/other significant damage has occurred, making it a posteriori. It is a necessary step to be taken to prevent … More Organizational/Systemic Failure: Root Cause Analysis

Organizational Failure: Is it Systemic? Part 1

April 26, 2022

In the following weeks, we will be looking at various case studies of safety incidents that had an organizational failure as one of the root causes. Let’s look inside the Chernobyl incident. As discussed in this article, the following organizational issues occurred: RBMK reactor design flaw concealed from clients Reactor was scheduled to be tested … More Organizational Failure: Is it Systemic? Part 1