đŽ Catastrophe is always just around the corner
This “Short Treatise on the Nature of Failure” hints at the frustration of our constant search for a “root cause”.  I found Dr. Cook’s perspective mind-expanding. đ§
Dr. Cook suggests in #7:
“Post-accident attribution to a âroot causeâ is fundamentally wrong.“
IÂ posted this article on LinkedIN and received several thoughtful comments.
Blackberry & Cross founder Omar Mora: “I have found many sources postulating the paradigm for “one, and only one cause”, disregarding the relationships, the “unfortunate series of events” interconnecting to create “the perfect storm”. This paradigm is so rigid that in many cases I see practitioners coming to a point of frustration: “man! we are not able to find the “real root cause”. đ¤¨
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Given the complexity and multiple contributing factors to failure, we don’t throw our hands up. We can shine a light on the unknown process steps by gathering and analyzing information about the inputs and outputs. It doesn’t have to be fancy. Just record the measurements and plot how they change over time. How far are we off target? How much variation is there? Watch what the process is doing naturally without any intervention. The simple baseline state can be illuminating! đĄ
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