Thanks for the clarification. This sounds like an interesting book.
The phrasing used on the web site is "Post-accident attribution to a ‘root cause’ is fundamentally wrong." At first glance, it sounds like the author means there is no cause that can be found so you shouldn't try to determine the cause. First they clarify by saying there are many causes not just one. However, this phrasing made me scratch my head:
> The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.
I don't know what other organizations are like, but where I work, when we do a "root cause analysis," we aren't literally looking for a single cause, despite the name. The "root cause" is almost always that pieces a, b, and c came together in an unexpected way. I can definitely think of places where I worked where they were mostly out to place blame, though, and I guess that's what they were trying to caution against.
I think blame is one way it can go bad, but not the only one. The whole framing of a "root cause" is dangerous, in that it encourages people to look for exactly one thing, and then not look beyond it when they find it. It sounds like your organization does decently in that regard, but they're doing it in spite of the "root cause" frame.
The phrasing used on the web site is "Post-accident attribution to a ‘root cause’ is fundamentally wrong." At first glance, it sounds like the author means there is no cause that can be found so you shouldn't try to determine the cause. First they clarify by saying there are many causes not just one. However, this phrasing made me scratch my head:
> The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.
I don't know what other organizations are like, but where I work, when we do a "root cause analysis," we aren't literally looking for a single cause, despite the name. The "root cause" is almost always that pieces a, b, and c came together in an unexpected way. I can definitely think of places where I worked where they were mostly out to place blame, though, and I guess that's what they were trying to caution against.