7. “Saying an event was caused by error
or not following procedure is like
saying an object fell due to gravity:
it’s always true,
it just doesn’t teach us anything”
Conklin, 2018
8. Traditional Approach (Black Line) Event
(Edwards)
The problem is, the failure probably was not
linear . . .
. . . and there almost NEVER is one root cause.
Why
Why
Why
Root Cause
Edwards
9. Blue Line Investigation
Latent Conditions
System Weaknesses
Near Misses
Local Factors
Normal Variability
Errors
Flawed processes
Poor communication
Production pressure
Resource constraints
Change in plans
Fear of reportingSystem Strengths
Design shortcomings
(Conklin/Edwards/Baker/Howe)Incomplete Procedures
Weak Signals
Personal Factors
Surprises
Data
Past Success
Unclear Signals
TradeoffsGoal Conflict
Adaptation
Time
13. Operational Learning Questions
(Conklin/Edwards/Baker/Howe)
Tell me about your work.
How far back in the process should we start for us to understand?
What does a good day look like (for this process)?
What is very unpredictable?
What is the worst thing that could happen in this process / area?
What near misses have we had?
What tools make the job easier?
What does a bad day look like?
What is very predictable?
Where is it easy to make a mistake?
16. Time line leading to the
actual event.
How the work is normally done by the
work force.
Procedures, training, instructions, etc.W.A.I.
W.A.N.
W.A.D.
Long
20. Don’t be linear
• Gaps will often have
multiple paths; follow
each path.
• Examine the
circumstances.
• Look for good outcomes,
not just where things
went wrong.
• Don’t be restricted to a
preformatted template.