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While You're Here
Blame Solves Nothing: Revisiting the Willie King Wrong-Site Amputation
In 1995, one of healthcare’s most notorious failures made headlines: a Florida surgeon amputated…
Preliminary Findings on Air India 171 Crash Confirm Key Theories and Raise New Questions
On June 12, 2025, Air India Flight 171, a Boeing 787-8 Dreamliner, crashed shortly after takeoff…
How to Navigate Management Pressure in a Root Cause Analysis
A question came up recently in one of our Cause Mapping® workshops: How do you keep management from…
Four Lessons from the Boeing 737 MAX 8 Crashes
One of the most common things I hear from organizations is: We keep having the same issues. We send…
The Air India Flight 171 Crash: What We Know So Far
This is our original report based on information available at the time. After new information has…