Skip to main content

Advertisement

Springer Nature Link
Log in

New vistas on causal-tree methods: from root cause analysis (RCA) to constructive cause analysis (CCA)

  • Original Article
  • Published:
Cognition, Technology & Work Aims and scope Submit manuscript

Abstract

Causal-tree methods such as root cause analysis (RCA) are the oldest and the most widespread methods used to analyze the causes of adverse events. They are often seen as essential prerequisites to risk control. Over the last few years, however, a number of limitations of RCA have been pointed out. Starting from the limitations currently identified and from our own occupational health and safety specialists’ experience, we have developed a new perspective for the analysis of accident causes, called constructive cause analysis (CCA). CCA is part of a tradition of activity-focused ergonomics. It posits that safety is mostly based upon the skills of individuals, at both operational and organizational levels, and it also leads to identifying positive elements in the analyzed situation. In line with the historico-cultural theory of activity, CCA serves the dual objectives of knowledge and action: the modifications found in CCA are based upon the confrontation of knowledge. The purpose of this article is to describe CCA. A case study from our own interventions illustrates the method.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Explore related subjects

Discover the latest articles, news and stories from top researchers in related subjects.

Notes

  1. This issue, regarding the evolution of work and the increasingly complex system modes, is not detailed in this article (Epstein 2008; Glouberman and Zimmerman 2002; Hollnagel 2008a; Le Coze 2005; Pariès 2006). Interested readers may consult the work of Amalberti (2001) or Hollnagel (2009).

  2. The main argument against this implementation of the method is that it is time consuming. This approach involves several people working for several hours. Our answer is based upon the literature findings. Studies have shown that the in-depth analysis of the causes of one or several events is more effective than the statistical processing of the set of identified risks (Amalberti 2001; Leclercq et al. 2013; Vincent 2004). In other words, it would appear to be more effective for several people to analyze one case fully than to have one person analyze several cases.

  3. The techniques mentioned are more about the analysis of the activity because it is more difficult to verbalize the activity than the task. It is, of course, also necessary to understand the task and the dialectical relation that exists between task and activity. Hence, these interviews must be supplemented by semi-structured interviews and document analysis to understand the task and the rationale behind the design of the work.

  4. This statement does not mean that all judgements, interpretations, and opinions should be removed from safety analyses. It only means that this type of information should be excluded at this stage of CCA. In parallel with CCA, the so-called naive causal explanations (i.e., those spontaneously provided by operators or the persons directly exposed to risks and accidents) constitute valuable information likely to throw light upon events and supplement the method. Before the CCA, they represent clues and leads for the data collection. Afterward, they open avenues to continue the intervention, extend it, or else think of new methods (Kouabenan 2009).

References

  • Amalberti R (2001) The paradoxes of almost totally safe transportation systems. Saf Sci 37(2–3):109–126

    Article  Google Scholar 

  • Amalberti R (2006) Optimum system safety and optimum system resilience: agonistic or antagonistic concepts? In: Hollnagel E, Woods D, Leveson N (eds) Resilience engineering: concepts and precepts. Ashgate, Aldershot, pp 253–270

    Google Scholar 

  • Amalberti R, Hourlier S (2007) Human error reduction strategies in Health Care. In: Carayon P (ed) Handbook of human factors and ergonomics in health care and patient safety. Lawrence Erlbaum Associates, Hillsdale, pp 561–577

    Google Scholar 

  • Bagnara S, Tartaglia R (2007) Patient safety: an old and new issue. Theor Issues Ergon Sci 8(5):365–369

    Article  Google Scholar 

  • Bagnara S, Parlangeli O, Tartaglia R (2010) Are hospitals becoming high reliability organizations? Appl Ergon 41(5):713–718

    Article  Google Scholar 

  • Barcellini F, Prost L, Cerf M (2015) Designers’ and users’ roles in participatory design: what is actually co-designed by participants? Appl Ergon 50:31–40. doi:10.1016/j.apergo.2015.02.005

    Article  Google Scholar 

  • Bationo-Tillon A, Decortis F (2016) Understanding museum activity to contribute to the design of tools for cultural mediation: new dimensions of activity? Le Travail Humain 1(76):53–70. doi:10.3917/th.791.0053

    Article  Google Scholar 

  • Béguin P (2009) Enhancing work practices within risky environments. In: Owen CA, Béguin P, Wackers G (eds) Risky work environments: reappraising human work within fallible systems. Ashgate, Aldershot UK, pp 149–152

    Google Scholar 

  • Béguin P (2014) The design of instruments as a dialogical process of mutual learning. In: Falzon P (ed) Constructive ergonomics. CRC Press, Paris

    Google Scholar 

  • Béguin P, Owen CA, Wakers G (2009) Shifting the focus on human work within complex socio-technical systems. In: Owen CA, Béguin P, Wackers G (eds) Risky work environments: Reappraising human work within fallible systems. Ashgate, Aldershot UK, pp 1–11

    Google Scholar 

  • Besnard D, Greathead D (2003) A cognitive approach to safe violations. Cogn Technol Work 5(4):272–282

    Article  Google Scholar 

  • Bisseret A, Sebillotte S, Falzon P (1999) Techniques pratiques pour l’étude des activités expertes. Octarès-Editions, Toulouse

    Google Scholar 

  • Blanchet A, Gotman A (2007) L’enquête et ses méthodes: l’entretien. Colin, Paris

    Google Scholar 

  • Bruner JS (1996) The culture of education. Harvard University Press, Cambridge

    Google Scholar 

  • Cahour B (2006) L’expérience vécue des utilisateurs: pourquoi l’étudier et comment ? Actes du colloque CITE 2006 (Coopération, Innovation, Technologie), Semaine de la Connaissance, Nantes 26–30 juin

  • Cahour B, Salembier P (2012) The user phenomenological experience; evoking the lived activity with “resituating interviews”. Paper presented at the CHI 2012 conference, computer–human interaction, Workshop “Theories behind User Experience research”, 5–10th of may, Austin

  • Carayon P (2007a) Handbook of human factors and ergonomics in health care and patient safety. Lawrence Erlbaum Associates, Hillsdale

    Google Scholar 

  • Carayon P (2007b) Human Factors and Ergonomics in Health Care and Patient Safety. In: Carayon P (ed) Handbook of human factors and ergonomics in health care and patient safety. Lawrence Erlbaum Associates, Hillsdale, pp 3–20

    Google Scholar 

  • Caroly S, Barcellini F (2014) The development of collective activity. In: Falzon P (ed) Constructive ergonomics. CRC Press, Paris

    Google Scholar 

  • Chesnais M (1993) Enseigner la prévention des risques professionnels, l’arbre des causes. INRS, Paris

    Google Scholar 

  • Chesnais M (2013a) Ergonomie et prévention: demandes et besoins en formation. In: Teiger C, Lacomblez M (eds) (Se) Former pour transformer le travail. Dynamiques de constructions d’une analyse critique du travail. Presses de l’Université Laval, Laval, pp 289–295

  • Chesnais M (2013b) L’arbres des causes: histoires des fondements et usages de la méthode. In: Teiger C, Lacomblez M (eds) (Se) Former pour transformer le travail. Dynamiques de constructions d’une analyse critique du travail. Presses de l’Université Laval, Laval, pp 470–478

  • Clot Y, Kostulski K (2011) Intervening for transforming: the horizon of action in the clinic of activity. Theory Psychol 21(5):681–696. doi:10.1177/0959354311419253

    Article  Google Scholar 

  • Clot Y, Santiago-Delefosse M (2004) La perspective historico-culturelle en psychologie. Présentation. Bulletin de psychologie 469(57–1):3–4

    Google Scholar 

  • Cru D (2014) Le risque et la règle. Le cas du bâtiment et des travaux publics, Eres

    Book  Google Scholar 

  • Cuny X, Weill-Fassina A (2012) Histoire des approches de la santé et de la sécurité au travail au 41, rue Gay-Lussac, Paris (De la physiologie et de la psychologie du travail à l’ergonomie). Perspectives interdisciplinaires sur le travail et la santé  [En ligne], 14(1) mis en ligne le 01 mai 2012, consulté le 01 octobre 2016. doi:10.4000/pistes.851

  • Cuvelier L (2016) Agir face aux risques, regard de l’ergonomie (Vol. 2016-01). Fondation pour une culture de sécurité industrielle, Collection Les Regards—Gratuitement téléchargeable sur, Toulouse. http://www.foncsi.org/

  • Cuvelier L, Falzon P, Granry JC, Moll MC, Orliaguet G (2012) Planning safe anesthesia: the role of collective resources management. Int J Risk Saf Med 24:125–136

    Google Scholar 

  • Daniellou F (1996) L’ergonomie en quête de ses principes, Débats épistémologiques. Octarès, Toulouse

    Google Scholar 

  • Daniellou F (2005) The French-speaking ergonomists’ approach to work activity: cross influences of field intervention and conceptual models. Theor Issues Ergon Sci 6(5):409–427

    Article  Google Scholar 

  • Daniellou F, Rabardel P (2005) Activity-oriented approaches to ergonomics: some traditions and communities. Theor Issues Ergon Sci 6(5):353–357

    Article  Google Scholar 

  • Daniellou F, Simard M, Boissières I (2011) Human and organizational factors of safety: state of the art. Retrieved from Toulouse, http://www.foncsi.org/fr/publications/collections/cahiers-securite-industrielle/human-and-organizational-factors-of-safety-state-of-the-art-1/human-and-organizational-factors-of-safety-state-of-the-art

  • Daniellou F, Le Gal S, Promé M (2014) Organisational simulation: anticipating the ability of an organisation to cope with daily operations and incidents. Paper presented at the 11th international symposium on human factors in organisational design and management (ODAM 2014) CPH conference

  • De la Garza C, Fadier E (2005) Towards proactive safety in design: a comparison of safety integration approaches in two design processes. Cogn Technol Work 7(1):51–62. doi:10.1007/s10111-005-0173-7

    Article  Google Scholar 

  • De Terssac G, Boissières I, Gaillard I (2009) La Sécurité en action. Octares, Toulouse

    Google Scholar 

  • Dechy N, Dien Y, Funnemark E, Roed-Larsen S, Stoop J, Valvisto T, Arellano ALV (2012) Results and lessons learned from the ESReDA’s Accident Investigation Working Group: introducing article to “Safety Science” special issue on “Industrial Events Investigation”. Saf Sci 50(6):1380–1391. doi:10.1016/j.ssci.2009.10.004

    Article  Google Scholar 

  • Decortis F (2013) L’activité narrative dans ses dimensions multi instrumentée et créative en situation pédagogique. Activités 10(1):3–30. http://www.activites.org/v10n31/v10n31.pdf

  • Dekker S (2002) Reconstructing human contributions to accidents: the new view on error and performance. J Saf Res 33(3):371–385

    Article  Google Scholar 

  • Dekker S (2003) Failure to adapt or adaptations that fail: contrasting models on procedures and safety. Appl Ergon 34(3):233–238

    Article  Google Scholar 

  • Dekker S (2014) The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making. Theor Issues Ergon Sci 16(3):202–213. doi:10.1080/1463922X.2014.955554

    Article  Google Scholar 

  • Dekker S (2015) Safety differently: human factors for a new era, 2nd edn. CRC Press, Boca Raton

    Google Scholar 

  • Del Rio Carral M, Santiago Delefosse M (2015) Interpretation of data in psychology: a false problem, a true issue. Philos Study 5(1):54–62

    Google Scholar 

  • Detchessahar M (2011) Santé au travail: quand le management n’est pas le problème mais la solution…. Revue française de gestion 214:89–105

    Article  Google Scholar 

  • Detchessahar M (2013) Faire face aux risques psycho-sociaux: quelques éléments d’un management par la discussion. Négociations 1(19):57–80. doi:10.3917/neg.019.0057

    Article  Google Scholar 

  • Detchessahar M, Journé B (2011) The conduct of strategic Episodes: a communicational perspective. Paper presented at EGOS conference, Goteborg

  • Dien Y (1998) Safety and application of procedures, or how do “they” have to use operating procedures in nuclear power plants? Saf Sci 29(3):179–187

    Article  Google Scholar 

  • Dien Y, Dechy N, Guillaume E (2012a) Accident investigation: from searching direct causes to finding in-depth causes—problem of analysis or/and of analyst? Saf Sci 50(6):1398–1407. doi:10.1016/j.ssci.2011.12.010

    Article  Google Scholar 

  • Dien Y, Dechy N, Stoop J (2012b) Perspectives regarding industrial events investigation. Saf Sci 50(6):1377–1379. doi:10.1016/j.ssci.2012.01.013

    Article  Google Scholar 

  • Edwards A (2011) Building common knowledge at the boundaries between professional practices: relational agency and relational expertise in systems of distributed expertise. Int J Educ Res 50(1):33–39. doi:10.1016/j.ijer.2011.04.007

    Article  Google Scholar 

  • Engestrom Y (2000) Activity theory as a framework for analyzing and redesigning work. Ergonomics 43(7):960–974. doi:10.1080/001401300409143

    Article  Google Scholar 

  • Engeström Y (2011) From design experiments to formative interventions. Theory Psychol 21(5):598–628. doi:10.1177/0959354311419252

    Article  Google Scholar 

  • Epstein S (2008) Unexampled Events, Resilience, and PRA. In: Hollnagel E, Nemeth C, Dekker S (eds) Resilience engineering perspectives: remaining sensitive to the possibility of failure, vol 1. Ashgate, Aldershot, pp 49–62

    Google Scholar 

  • Fadier E (1990) Fiabilité humaine: méthodes d’analyse et domaines d’application. In: Leplat J, De Terssac G (eds) Les facteurs humains de la fiabilité dans les systèmes complexes. Octarès, Marseille, pp 47–80

    Google Scholar 

  • Fahlbruch B, Schöbel M (2011) SOL—safety through organizational learning: a method for event analysis. Saf Sci 49(1):27–31. doi:10.1016/j.ssci.2010.05.004

    Article  Google Scholar 

  • Falzon P (2008) Enabling safety: issues in design and continuous design. Cogn Technol Work 10:7–14

    Article  Google Scholar 

  • Falzon P (2014) Constructive ergonomics. Taylor & Francis, London

    Book  Google Scholar 

  • Faverge J-M (1970) The operator’s reliability and safety in industry [L’homme, agent d’infiabilité et de fiabilité du processus industriel]. Ergonomics 13:301–327

    Article  Google Scholar 

  • Ferjencik M (2010) Root cause analysis of an old accident in an explosives production plant. Saf Sci 48(10):1530–1544. doi:10.1016/j.ssci.2010.06.003

    Article  Google Scholar 

  • Fischhoff B (2003) Hindsight =/= foresight: the effect of outcome knowledge on judgment under uncertainty. Quality Saf Health Care 12(4):304–311. doi:10.1136/qhc.12.4.304

    Article  Google Scholar 

  • Flanagan JC (1954) La technique de l’incident critique. Revue de Psychologie Appliquée 4(3):267–295

    Google Scholar 

  • Garrigou A, Carballeda G, Daniellou F (1998) The role of ‘know-how’ in maintenance activities and reliability in a high-risk process control plant. Appl Ergon 29(2):127–131. doi:10.1016/S0003-6870(96)00060-9

    Article  Google Scholar 

  • Glouberman S, Zimmerman B (2002) Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?. Commission on the future of heath care in canada

  • Haims MC, Carayon P (1996) Implementation of an “in-house” participatory ergonomics program: a caase study in a public service organization. In: Brown VO, Hendrick HW (eds) Human factors in organizational design and management. Elsevier, Amsterdam, pp 175–180

    Google Scholar 

  • Hakkarainen K, Olson DR (2009) The uses of evidence in accident analysis by professionally versus scientifically trained investigators. Revue Européenne de Psychologie Appliquée/European Review of Applied Psychology 59(4):253–264. doi:10.1016/j.erap.2009.04.003

    Article  Google Scholar 

  • Henriksen K, Kaplan H (2003) Hindsight bias, outcome knowledge and adaptive learning. Quality Saf Health Care 12(suppl 2):ii46–ii50. doi:10.1136/qhc.12.suppl_2.ii46

    Google Scholar 

  • Hollnagel E (2008a) The changing nature of risks. HFESA J Ergonom Aust 22(1):33–46

    Google Scholar 

  • Hollnagel E (2008b) Risk + barriers = safety? Saf Sci 46(2):221–229

    Article  Google Scholar 

  • Hollnagel E (2009) The ETTO principle: efficiency—thoroughness trade-off. Why things that go right sometimes go wrong?. Ashgate, Farnham

    Google Scholar 

  • Hollnagel E (2012) Resilience engineering and the systemic view of safety at work: Why work-as-done is not the same as work-as-imagined. Bericht zum 58. Kongress der Gesellschaft für Arbeitswissenschaft, Dortmund. GfA-Press, pp 19–24

  • Hollnagel E (2014) Is safety a subject for science? Saf Sci 67(in press):21–24. doi:10.1016/j.ssci.2013.07.025

  • Hollnagel E, Woods D, Leveson N (2006) Resilience engineering: concepts and precepts. Ashgate, Aldershot

    Google Scholar 

  • Hollnagel E, Pariès J, Woods D, Wreathall J (2010) Resilience Engineering in Practice: A Guidebook (Vol. 3 Resilience Engineering Perspectives). Ashgate, Farnham, UK

  • ICSI (2013) Facteurs Humains et Organisationnels de la sécurité: l’analyse approfondie d’événement. Cahiers de la Sécurité Industrielle, Institut pour une Culture de Sécurité Industriell (ICSI), 2014-04

  • Iedema R (2011) Creating safety by strengthening clinicians’ capacity for reflexivity. BMJ Qual Saf 20(Suppl 1):i83–i86. doi:10.1136/bmjqs.2010.046714

    Article  Google Scholar 

  • Iedema R, Jorm C, Braithwaite J, Travaglia J, Lum M (2006) A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. Soc Sci Med 63(5):1201–1212. doi:10.1016/j.socscimed.2006.03.035

    Article  Google Scholar 

  • INRS (2013) L’analyse de l’accident de travail. La méthode de l’arbre des causes ED 6163

  • Kaptelinin V, Nardi B (2006) Acting with technology: activity theory and interaction design. MIT Press, Cambridge

    Google Scholar 

  • Klein G, Armstrong A (2005) Critical decision method. In: Stanton N, Hedge A, Brookhuis K, Salas E, Hendrick H (eds) Handbook on human factors and ergonomics methods. CRC Press, Boca Raton, pp 35.31–35.38

    Google Scholar 

  • Kouabenan DR (2009) Role of beliefs in accident and risk analysis and prevention. Saf Sci 47:767–776

    Article  Google Scholar 

  • Kum S, Sahin B (2015) A root cause analysis for arctic marine accidents from 1993 to 2011. Saf Sci 74:206–220. doi:10.1016/j.ssci.2014.12.010

    Article  Google Scholar 

  • Kvale S (1996) Interviews an introduction to qualitative research interviewing. Sage Publications, London

    Google Scholar 

  • Kvale S, Brinkmann S (2009) Interviews: learning the craft of qualitative research interviewing. Sage, Los Angeles

    Google Scholar 

  • Le Coze JC (2005) Are organisations too complex to be introduced in technical risk assessment and current safety auditing? Saf Sci 43:613–638

    Article  Google Scholar 

  • Le Coze JC (2008) Disasters and organisations: from lessons learnt to theorizing. Saf Sci 46:132–149

    Article  Google Scholar 

  • Le Coze JC (2013) What have we learned about learning from accidents? Post-disasters reflections. Saf Sci 51(1):441–453. doi:10.1016/j.ssci.2012.07.007

    Article  Google Scholar 

  • Le Coze JC (2015) Reflecting on Jens Rasmussen’s legacy (2) behind and beyond, a ‘constructivist turn’. Appl Ergon. doi:10.1016/j.apergo.2015.07.013

    Google Scholar 

  • Le Moigne J-L (1995) Les épistémologies constructivistes. P.U.F, Paris

    Google Scholar 

  • Le Moigne J-L (2001) Pourquoi je suis un constructiviste non repentant. Revue du Mauss 1(17):197–223

    Article  Google Scholar 

  • Leclercq S, Monteau M, Cuny X (2013) Quels modèles pour prévenir les accidents du travail d’aujourd’hui ? Le Travail Humain 2(76):105–127. doi:10.3917/th.762.0105

    Article  Google Scholar 

  • Leplat J (1988) Task complexity in work situations. In: Goodstein LP, Andersen HB, Olsen SE (eds) Task, errors and mental models. Taylor and Francis, London

    Google Scholar 

  • Leplat J, Cuny X (1974) Les accidents du travail. PUF, Paris

    Google Scholar 

  • Leveson N (2004) A new accident model for engineering safer systems. Saf Sci 42(4):237–270

    Article  Google Scholar 

  • Leveson N (2011) Applying systems thinking to analyze and learn from events. Saf Sci 49(1):55–64. doi:10.1016/j.ssci.2009.12.021

    Article  Google Scholar 

  • Llory M (1997) Human- and work-centered safety: keys for a new conception of management. Ergonomics 40(10):1148–1158

    Article  Google Scholar 

  • Lundberg J, Rollenhagen C, Hollnagel E (2009) What-You-Look-For-Is-What-You-Find—the consequences of underlying accident models in eight accident investigation manuals. Saf Sci 47(10):1297–1311

    Article  Google Scholar 

  • Lundberg J, Rollenhagen C, Hollnagel E (2010) What you find is not always what you fix-How other aspects than causes of accidents decide recommendations for remedial actions. Accid Anal Prev 42(6):2132–2139

    Article  Google Scholar 

  • Marc J, Rogalski J (2009) Collective management in dynamic situations: the individual contribution. Cogn Technol Work 11(4):313–327

    Article  Google Scholar 

  • Miller A, Xiao Y (2007) Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre. Cogn Technol Work 9:51–66

    Article  Google Scholar 

  • Mollo V, Nascimento A (2014) Reflective practices and the development of individuals, collectives, and organizations. In: Falzon P (ed) Constructive Ergonomics. CRC Press, Paris

    Google Scholar 

  • Monteau M, Krawsky G, Cuny X (1972) Méthode pratique de recherche de facteurs d’accidents. Rapport INRS n°77/RE, Nancy

  • Morel G, Chauvin C (2006) A socio-technical approach of risk management applied to collisions involving fishing vessels. Saf Sci 44(7):599–619. doi:10.1016/j.ssci.2006.01.002

    Article  Google Scholar 

  • Morin E (2005) Introduction à la pensée complexe. Éditions du seuil, Paris

    Google Scholar 

  • Morin E (2008) On complexity. Hampton Press, Cresskill

    Google Scholar 

  • Mulholland P, Zdrahal Z, Domingue J (2005) Supporting continuous learning in a large organization: the role of group and organizational perspectives. Appl Ergon 36(2):127–134. doi:10.1016/j.apergo.2004.09.009

    Article  Google Scholar 

  • Munoz G, Vidal-Gomel C, Bourmaud G (2015) The operators’ system of instruments: a risk management tool. In: Mercantini J-M, Faucher C (eds) Risk and Cognition, vol 80. Springer, Berlin, pp 229–247

    Google Scholar 

  • Nascimento A, Cuvelier L, Mollo V, Dicioccio A, Falzon P (2014) Constructing safety: from the normative to the adaptive view. In: Falzon P (ed) Constructive Ergonomics. CRC Press, Boca Raton

    Google Scholar 

  • Neily JB, Ogrinc G, Mills P, Williams R, Stalhandske E, Bagian J, Weeks W (2003) Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf 29(3):434–439

    Article  Google Scholar 

  • Newman L (2005) Interview Method. In: Stanton N, Hedge A, Brookhuis K, Salas E, Hendrick H (eds) Handbook on human factors and ergonomics methods. CRC Press, Boca Raton

    Google Scholar 

  • Nicolini D, Waring J, Mengis J (2011) Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med 73(2):217–225. doi:10.1016/j.socscimed.2011.05.010

    Article  Google Scholar 

  • Nonaka I (1994) A dynamic theory of organizational knowledge creation. Organ Sci 5(1):14–37

    Article  Google Scholar 

  • Norros L (2014) Developing human factors/ergonomics as a design discipline. Appl Ergon 41(1):61–71. doi:10.1016/j.apergo.2013.04.024

    Article  Google Scholar 

  • Noulin M (2002) Ergonomie. Octarès, Toulouse

    Google Scholar 

  • NRI foundation (2009) The NRI MORT User’s Manual, 2nd edn. Washington, DC

    Google Scholar 

  • Nyssen AS (2007) Coordination in hospitals: organized or emergent process? Cogn Technol Work 9(3):149–154

    Article  Google Scholar 

  • Osorio C, Clot Y (2010) L’analyse collective des accidents du travail: Une méthode d’analyse pour intégrer la dimension subjective et développer le genre professionnel. Activités 7(2):28–41

    Google Scholar 

  • Palaci F, Agnès P, Benchekroun TH (2009) L’accident du travail au carrefour de l’organisation du travail et de l’organisation de la prévention. Communication présentée au 44e Congrès de la Société d’Ergonomie de Langue Française, Toulouse, 22–24 septembre

  • Pariès J (2006) Complexity, emergence, resilience. In: Hollnagel E, Woods D, Leveson N (eds) Resilience engineering: Concepts and precepts. Ashgate, Aldershot, pp 43–53

    Google Scholar 

  • Patterson E, Woods D, Cook R, Render M (2007) Collaborative cross-checking to enhance resilience. Cogn Technol Work 9(3):155–162

    Article  Google Scholar 

  • Pearl J (2000) Causality: models, reasoning, and inference. Cambridge University Press, Cambridge

    MATH  Google Scholar 

  • Pécaud D (2010) Ingénieries et Sciences Humaines, la prévention des risques en dispute. Lavoisier, collection Sciences du risque et du danger, Paris

    Google Scholar 

  • Peerally MF, Carr S, Waring J, Dixon-Woods M (2016) The problem with root cause analysis. BMJ Qual Saf. doi:10.1136/bmjqs-2016-005511

    Google Scholar 

  • Petit J, Coutarel F (2014) Interventions as dynamic processes for the joint development of stakeholders and organizations. In: Falzon P (ed) Constructive ergonomics. CRC Press, Paris

    Google Scholar 

  • Pidgeon N, O’Leary M (2000) Man-made disasters: why technology and organizations (sometimes) fail. Saf Sci 34(1):15–30

    Article  Google Scholar 

  • Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27(2–3):183–213

    Article  Google Scholar 

  • Re A, Macchi L (2010) From cognitive reliability to competence? An evolving approach to human factors and safety. Cogn Technol Work 12(2):79–85

    Article  Google Scholar 

  • Reason J (1990) Human error. Cambridge University Press, New York

    Book  Google Scholar 

  • Rocha R, Mollo V, Daniellou F (2015) Work debate spaces: a tool for developing a participatory safety management. Appl Ergon 46(Part A(0)):107–114. doi:10.1016/j.apergo.2014.07.012

    Article  Google Scholar 

  • Rooney JJ, Vanden Heuvel LN (2004) Root cause analysis for beginners. Qual Prog 37:45–53

    Google Scholar 

  • Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB (2007) Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin 25(2):361–376

    Article  Google Scholar 

  • Saleh JH, Pendley CC (2012) From learning from accidents to teaching about accident causation and prevention: multidisciplinary education and safety literacy for all engineering students. Reliab Eng Syst Saf 2012(99):105–113

    Article  Google Scholar 

  • Sannino A, Sutter B (2011) Cultural-historical activity theory and interventionist methodology: classical legacy and contemporary developments. Theory Psychol 21(5):557–570. doi:10.1177/0959354311414969

    Article  Google Scholar 

  • Schöbel M, Manzey D (2011) Subjective theories of organizing and learning from events. Saf Sci 49(1):47–54. doi:10.1016/j.ssci.2010.03.004

    Article  Google Scholar 

  • Schön D (1983) The reflective practitioner. How professionals think in action, London Temple Smith

    Google Scholar 

  • Schwartz Y (2000) Le paradigme ergologique ou un métier de philosophe. Octarès Éditions, Toulouse

    Google Scholar 

  • Seidl D, Whittington R (2014) Enlarging the strategy-as-practice research agenda: towards taller and flatter ontologies. Organ Stud 35:1–15

    Article  Google Scholar 

  • Sheridan T (2008) Risk, human error, and system resilience: fundamental ideas. Hum Factors 50(3):418–426. doi:10.1518/001872008x250773

    Article  MathSciNet  Google Scholar 

  • Star S, Griesemer J (1989) Institutional ecology, ‘translations’ and boundary objects: amateurs and professionals in berkeley’s museum of vertebrate zoology, 1907-39. Soc Stud Sci 19(3):387–420. doi:10.1177/030631289019003001

    Article  Google Scholar 

  • Taylor-Adams S, Vincent C, Stanhope N (1999) Applying human factors methods to the investigation and analysis of clinical adverse events. Saf Sci 31(2):143–159

    Article  Google Scholar 

  • Teiger C (1996) The cooperation between trade unionists and ergonomists: the stakes involved in training trade unionists in ergonomic work analysis. Saf Sci 23(2):119–124. doi:10.1016/0925-7535(96)00055-0

    Article  Google Scholar 

  • Teiger C, Lacomblez M (2013) (Se) Former pour transformer le travail. Dynamiques de constructions d’une analyse critique du travail. Presses de l’Université Laval, Laval

  • Teiger C, Montreuil S (1996) The foundation and contributions of ergonomics work analysis in training programs. Saf Sci 23(3):81–95

    Article  Google Scholar 

  • Thellier S, Falzon P, Cuvelier L (2015) Construction of an “activity sharing space” to improve healthcare safety. 32nd Annual conference of the european association of cognitive ergonomics (ECCE 2015). 1–3 July, Warsaw

  • Thellier S, Cuvelier L, Falzon P, Jeffroy F (2016) Risk analysis by healthcare professionals in radiotherapy: assessing difficulties, developing a method. International conference on healthcare systems, ergonomics and patient safety (HEPS), 4–7 oct., Toulouse

  • Trompette P, Vinck D (2009) Revisiting the notion of Boundary Object Revue d’anthropologie des connaissances 1(3):3–25

    Article  Google Scholar 

  • U.S. Department of Energy (2013) DOE handbook: accident and operational safety analysis (Vol. Vol.1: accident analysis techniques). U.S. Department of Energy, Washington, DC

  • Van Belleghem L (2016) Eliciting activity: a method of analysis at the service of discussion. Le Travail Humain 79(3):285–306

    Article  Google Scholar 

  • Van Belleghem L, Forcioli Conti E (2015) Une ingénierie de la discussion? Chiche! 50ème congrès de la SELF, Paris les 23, 24, 25 septembre 2015

  • Vermersch P (2011) L’entretien d’explicitation. ESF, Paris

    Google Scholar 

  • Vincent C (2004) Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 13:242–243

    Article  Google Scholar 

  • Vincent C, Taylor-Adams S, Stanhope N (1998) Framework for analyzing risk and safety in clinical medicine. Br Med J 316:1154–1157

    Article  Google Scholar 

  • Volkoff S (2005) L’ergonomie et les chiffres de la santé au travail: ressources, tensions et pièges. Octarès, Toulouse

    Google Scholar 

  • Von Krogh G, Roos J (1995) Convers Manag Eur Manag J 13(4):390–394

    Google Scholar 

  • Weill-Fassina A, Kouabenan DR, De la Garza C (2004) Analyse des accidents du travail, gestion des risques et prévention. In: Brangier E, Lancry A, Louche C (eds) Les Dimensions Humaines du Travail: Théorie et pratique de psychologie du travail et des organisations. Presses Universitaires de Nancy, Nancy, pp 251–283

    Google Scholar 

  • Whittington R, Melin L (2003) The challenge of organizing/strategizing. In: Pettigrew A, Whittington R, Melin L, Sánchez-Runde C, van den Bosch F, Ruigrok X, Numagami T (eds) Innovative forms of organizing: International perspectives. SAGE Publications, London, pp 34–49

    Chapter  Google Scholar 

  • Wilson JR, Haines HM (1997) Participatory ergonomics. In: Salvendy G (ed) Handbook of human factors and ergonomics. Wiley, New York, pp 490–513

    Google Scholar 

  • Woods D, Cook R (2002) Nine steps to move forward from error. Cogn Technol Work 4(2):137–144

    Article  Google Scholar 

  • Woods D, Hollnagel E (2006) Prologue: Resilience engineering concepts. In: Hollnagel E, Woods D, Leveson N (eds) Resilience engineering: concepts and precepts. Ashgate, Aldershot, pp 1–6

    Google Scholar 

Download references

Acknowledgements

This article would never have seen the light of day without the inquisitive, candid, or challenging discussions held with the CNAM audiences and Paris 8 students. I am especially grateful to Anne Bationo-Tillon and Jacques Leplat who have the knack of opening new avenues for thought with a couple of words in a corridor.

Author information

Authors and Affiliations

  1. Equipe Conception, Création, Compétences, Usages, Laboratoire Paragraphe, UFR de psychologie, Université Paris 8, 2 rue de la liberté, 93 526, Saint-Denis, France

    Lucie Cuvelier

  2. Cnam, 41 rue Gay Lussac, 75005, Paris, France

    H. Bencheckroun

  3. Laboratory Ergonomics and Safety of Maritime Activities, University of South Brittany, Rue de saint Maudé, 56321, LORIENT Cedex, France

    G. Morel

Authors
  1. Lucie Cuvelier
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. H. Bencheckroun
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. G. Morel
    View author publications

    You can also search for this author inPubMed Google Scholar

Corresponding author

Correspondence to Lucie Cuvelier.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cuvelier, L., Bencheckroun, H. & Morel, G. New vistas on causal-tree methods: from root cause analysis (RCA) to constructive cause analysis (CCA). Cogn Tech Work 19, 13–30 (2017). https://doi.org/10.1007/s10111-017-0404-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10111-017-0404-8

Keywords