Intended to focus on maximal learning about all factors that contributed to an accident. It subsumes several approaches, including a blameless analysis and that each factor doesn't just have a single "cause" but that different factors form a network of interaction.
Also nitpicking about the headline: You haven't been in a place crash because you wouldn't be reading this if you were :)
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-wr...)
Thank 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.
Thanks 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
Yeah, probably, and the counterfactual where airlines were worse at preventing crashes would probably have worse crash survival rates as well. Maybe planes bumping into each other at very low speeds on the ground would skew the stats in that case, but you know what I mean by "plane crash".
>In round and, of course, fluctuating figures it is estimated that of the 1500 who die each year in air transport accidents some 900 die in non-survivable accidents. The other 600 die in accidents which are technically survivable and crashworthiness, fire and evacuation issues are all important. Of these 600 perhaps 330 die as a direct result of the impact and 270 due to the effects of smoke, toxic fumes, heat and resulting evacuation problems.
> Also nitpicking about the headline: You haven't been in a place crash because you wouldn't be reading this if you were :)
Do you mean to imply that being in a plane crash is certain to result in death? Because that's definitely not true. Even when they crash hard enough to explode, there are sometimes still survivors.
Intended to focus on maximal learning about all factors that contributed to an accident. It subsumes several approaches, including a blameless analysis and that each factor doesn't just have a single "cause" but that different factors form a network of interaction.
Also nitpicking about the headline: You haven't been in a place crash because you wouldn't be reading this if you were :)