added from Pre-Accident Investigations

README.md

@@ -34,6 +34,10 @@ Vesel, C. (2012) [Language bias in accident investigation](https://lup.lub.lu.se
 
 > This theory simplifies the idea of causation by limiting the search for cause to singular 'chains of events', which does not take into account the complexity of nature (e.g. fire), where multiple action chains may exist concurrently. One property of a complex system is emergence, which refers to phenomena that are new and not explicable by the properties of their components (2009; S. E. Page, 2011). This is different than resultant phenomena, which can be linked directly to other entities or events.
 
+Conklin, Todd. (2016) Pre-Accident Investigations. Better Questions--an Applied Approach to Operational Learning.
+
+> (p. 126) In the past, as a safety leader, when investigating an accident or injury I would start at the event and ask “Why?” five times looking for the “root cause.” This approach seemed to satisfy my basic need to understand and explain why the event occurred and then gave me the ability to fix something. As a safety leader and experienced engi- neer, it seemed like a concise method and provided me with an explain- able linear path that led to the failure. Fix the root cause, and the problem was solved. The problem with my thinking was multifaceted. First, I have found that I was so focused on finding a “root cause” that I was not look- ing at all of the conditions that led to the event. As I began to change my approach, I noticed that if I focused more on learning and discovery instead of fixing. I ended up with a more comprehensive story of “how” the event occurred, instead of just “why.” It has also become quite evi- dent to me that failure is not so linear as I thought. The 5-whys approach tended to build a linear path of what appeared to be “cause and effect” where I think it actually was more of an “effect-and-cause” picture of the event. I would see the effect and then sort of create or determine the cause. The more Learning Teams I led, the more I realized that failure is actually incredibly complicated in most situations.
+It now seems to me that there is no real path to failure or “chain of events” as we used to talk about in the army. I have reached a point now where I do not think there is a “root cause” or even “root causes.” It seems to me that many of the things that lead to failure are simply normal vari- ability that eventually align in such a fashion with other conditions and hazards that lead to something bad happening. In fact, the search for root cause had often led me to believe I had fixed the problem when actually I only fixed one piece of the failure; perhaps it was only the triggering event. In reality, there were numerous other conditions that coupled to bring about the bad event.
 
 ### On the usage of the term
 
@@ -44,4 +48,4 @@ Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). [The problem wi
 Vincent, C. A. (2004). [Analysis of clinical incidents: a window on the system not a search for root causes](https://www.researchgate.net/publication/8420168_Analysis_of_clinical_incidents_A_window_on_the_system_not_a_search_for_root_causes). Quality and Safety in Health Care, 13(4), 242–243. https://doi.org/10.1136/qshc.2004.010454
 
 
-> The term ‘‘root cause analysis’’, while widespread, is misleading in a number of respects. To begin with, it implies that there is a single root cause, or at least a small number. Typically, however, the picture that emerges is much more fluid and the notion of a root cause is a gross oversimplification.
+> The term ‘‘root cause analysis’’, while widespread, is misleading in a number of respects. To begin with, it implies that there is a single root cause, or at least a small number. Typically, however, the picture that emerges is much more fluid and the notion of a root cause is a gross oversimplification.