Root cause analysis is the name of the game: investigate the accident until the single, underlying cause is found. What this ought to mean is that when people have indeed made erroneous decisions or actions, we should determine what caused them to err. This is what root cause analysis ought to be about. Alas, all too often it stops once a person is found to have acted inappropriately.
( Donald A. Norman )
[ The Design of Everyday Things ]
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