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Whoever got curious enough to enter this comment section: carve out some time to read the CAST handbook. It changed how I look at accidents but also how I look
by kqr 3y ago
Whoever got curious enough to enter this comment section: carve out some time to read the CAST handbook. It changed how I look at accidents but also how I look at organisations and the rest of the world. Should be mandatory reading for anyone in any position of responsibility.
I have long wanted to write a review/summary of it on my blog but it's so dense in useful content it's hard to compress further. (There's a reason I have not published it so please try not to judge it for its rough edges, but this is what the draft looked like when I gave up last time: https://two-wrongs.com/root-cause-analysis-youre-doing-it-wrong.html https://two-wrongs.com/root-cause-analysis-youre-doing-it-wr...)
- tudorw 3y agoThanks for that, I really appreciated this breakdown of the accident at Three Mile Island and the concept of 'the second story' with regards systems thinking; https://www.youtube.com/watch?v=1xQeXOz0Ncs https://www.youtube.com/watch?v=1xQeXOz0Ncs
- growingkittens 3y agoThank you for posting your summary! I appreciate summaries because each individual finds something different to emphasize about the text. Have you looked at the book "Handbook of Systems Thinking Methods" (2023, Salmon, Stanton, et al)? It's all about applying systems thinking to safety and talks about the STAMP-CAST model.