Quote #24 - investigation should find system failure

Quote #24 - Investigations are to find real causes I has occurred to me that what is failing in safety is the investigation process and of those who do the investigation to find real causes.  I have done a few investigations and in many of those I have listed the main causes of failure as management/system failure (before i knew of SD)...they were not well received by my manager/s and in some cases my report was binned and completely re done by agreeable group-thinking safety people who were to afraid to be honest and noted the workers as the cause (and don't dare call that orthodox safety..maybe orthodox ethics!!!).. I can also say I was not liked and outcast for being honest...which is why I think it is funny the promotion of Just Cultures...(I have obviously been in the real game unlike these snake oil academic sellers who live in dreamerstan) I suppose that is why we should adapt one investigation method...https://lnkd.in/g4jptfN have no internal investigations for any serious event, they should all be done by 3rd parties to limit bias and corruption. But lets say the evidence is correct and all investigation were done competently (cough)...then proof would say that workers are cause... Safety Cynic -  just cause!