Root Cause: bad review / cures for the real causes
- The actual root causes were in the reward system, some unreasonable
expectations, and the lack of tools to deal with the complexity of
Our safety basis is extremely complex, coupled with an extremely
complex and multi-headed customer, and unclear responsibility lines in
our organization (unclear requirements at interfaces)
The dependence on reviews for document quality is unreasonable, but
understandable given the growth history here. Each change has a large
number of potential impacts on different highly specialized
organizations, each of which needs input on how the change is
implemented to avoid conflicts and non-compliances with numerous
oversight orgs and customers. (cures causing the next event)
The challenge is getting all the impacts identified and input received
from all these separate and often contradictory interests.
I know there are Knowledge Management softwares out there that could
help us to bring the specialist knowledge base to the change initiator
at the start, but thought someone here might steer me to some that will
do the following:
Work from a change request document rather than the initiator having to
build a search profile.
Use AI to improve the profile engine over time
Access any format document, including doing OCR on scanned documents.
Work from windows machines and on multiple mainframe operating