One of the most dangerous things about the safety curriculum is its indoctrination about causation. Many of the semiotics of causation such as the swiss-cheese (Reason) and dominos (Heinrich), are simply not true. Both models are completely made up and don’t exist in reality.

The reality of life is that: events are messy, life is complex, much of what we do is disorderly and not linear.

The idea that one can go back over an event looking for some ‘root cause’ or linear progression of events is absolute nonsense. What is more, this kind of indoctrination is dangerous. Looking for a root cause or for a linear movement of causes is an attribution on events, it is not how events unfold.

If one is thinking about event investigations and looking for cause, the following model is much more helpful than the rubbish James Reason and Heinrich concocted (See Figure 1. SPoR Swiss Cheese Model)

Figure 1. SPoR Swiss Cheese Model

As much as safety would like the world to be simple, ordered and predictable, it is NOT so.

For example, every parent knows in the simple existence of a fight between 2 children, one can never find cause. The moment you involve people in any investigation you are not likely to find a root cause, indeed, many court cases and coronial enquiries don’t find ‘root cause’.

So, stop looking for root cause and attributing a model onto an event, looking for what doesn’t exist. The belief in root cause says much more about the indoctrination of the safety curriculum than it does about the reality of causation.

When you place an ideology of order on disorder all that happens is a search to prove unfounded assumptions.

Most of the models created by Safety that dominate the curriculum are myth.

In SPoR, we use various models of ‘causal loop’ mapping to help get a better idea of how events unfold, are interconnected and generate by-products that are not seen in traditional safety causation models. See Figure 2. Causal Loop Mapping.

Figure 2. Causal Loop Mapping

What happens in real life is the meandering of events that looks something like this: Figure 3. The Wandering Way.

Figure 3. The Wandering Way

When one places a structure over this one gets the idea that the disorder of the wandering can be controlled, measured and deconstructed. This is what happens when one accepts the assumptions of safety indoctrination about causation. See Figure 4. Controlling Disorder.

Figure 4. Controlling Disorder.

 The swiss-cheese and domino models are concoctions of James Reason and Heinrich, they are NOT a reflection of reality. Yet, these nonsense models still dominate the safety curriculum.

There has been little that is more destructive and misleading in safety than the nonsense of Heinrich and James Reason (https://safetyrisk.net/faith-in-reason-and-unreasoned-faith-as-safety-myth/; https://safetyrisk.net/no-good-reason-to-follow-reason/ ). And don’t get started on Reason’s useless 5 cultural ‘types’ that have nothing to do with culture.

What we have now are investigation models based on this nonsense such as iCAM (https://safetyrisk.net/deconstructing-icam-useful-or-useless/), a useless method for incident investigations. All iCAM does is affirm the assumptions of its own linear method, it doesn’t encourage an open investigation. And yet, I am told this model is some sort of ‘industry standard’. Obviously, when you don’t know what to do, make st up.

Yet we see the AIHS Body of NON-Knowledge endorsing nonsense causality concoctions that have no evidential foundation (https://safetyrisk.net/causation-concoctions/).

Why search for intelligence in risk when a believable myth will do. It’s so easy to sell propaganda to an uncritical industry (https://safetyrisk.net/why-deliver-outcomes-when-propaganda-will-do/) than to understand the complexities of human activity.

It’s so easy to sell slogans and call them principles, when a poorly educated audience (including the presenter) has no idea of the difference between ethics, moral, values, principles, law, regulation, virtue and beliefs.

Such ignorance simply enables more mythology eg. that safety is a value. No, it is not. A value is not something that is values. Safety can be valued but it is NOT a value (https://safetyrisk.net/we-can-value-safety-but-safety-is-not-a-value/).

The astounding ignorance about ethics in the safety industry, simply enables propaganda and indoctrination to thrive. We see this in the sloganeering of HOP. Search everything HOP presents and you will find no clearly articulated ethic or an understanding of ethics.

When someone things principles are like the bank of a river and that rivers flow into lakes, you know the presentation is bankrupt and has no idea of ethics.

So, back to causation.

If you have been told the world is flat, you will go looking for evidence that the world is flat (https://en.wikipedia.org/wiki/Flat_Earth). And, it doesn’t matter how much evidence is produced, the flat-earthers continue in their belief (https://www.scientificamerican.com/podcast/episode/flat-earthers-what-they-believe-and-why/).

This is the same for linear and root cause. All the evidence points to the opposite of these assumptions but Safety continues to maintain its belief. How can it believe anything else when it is endorsed by the ignorance of the safety curriculum? This says much more about the nature of belief than the nature of reality. Just because the safety curriculum tells a myth, doesn’t make it true.

Indeed, if the safety curriculum promoted critical thinking, the mythical nonsense of linear causation would not exist. Similarly, the nonsense of zero.

If you are interested in learning about a better approach to investigations and critical thinking about risk causation, you can study the SPoR SEEK program (https://cllr.com.au/product/seek-the-social-psychology-of-event-investigations-unit-2-elearning/) that provides a positive, constructive and open approach to investigations.