3995 shaares
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64 private links
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failure
A bit heavy handed in the way it tries to paint Root Cause Analysis as evil. Still it has good points about its shortcomings. In particular I appreciate the emphasis on complexity which indeed points to have contributing factors and unexpected outcomes. Definitely things to keep in mind for any postmortem efforts.
Interesting story on how power plays can sometimes completely hide the fate of a project until it's too late. Definitely a cautionary tale.
If you want to get to the bottom of a problem and of why an accident happen, people need psychological safety. This is indeed necessary if you want them to share truthfully why the accident happened in the first place. Otherwise fear will drive the conversation and hide important facts.