Publications

In July 2017, the Organization 630 senior manager requested that an assessment of selected causal analyses be performed for the period from July 2014 to July 2017. As a result, this assessment reviewed causal analyses performed by or for Environment, Safety and Health (ES&H) Center department personnel during the specified period. The purpose was to determine the degree to which ES&H Center personnel learn from use of the causal analysis process.

A key element of successful world-class technical organizations is the ability to learn from problems, large and small. Mature technical organizations have procedures that support this learning process, but it is not the procedures alone that cause the organization to succeed. Organizational success is the result of managers understanding the objectives of learning from problems and the discipline managers bring to bear to follow through on corrective actions. Following through includes checking if the actions fixed the problem and to implement alternate actions if the original actions did not achieve the objectives.

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