Kaiser Permanente EHS representatives Shari Samuels and Teodoro Millon gave a talk today at EHSSENTIALS 2017 UCLA about how cause-effect mapping can be used to improve incident analysis and reduce recurrence. The duo stressed the importance of asking "Why?" when conducting incident analysis. Samuels demonstrated how process maps and cause-effect maps can be used in conjunction to identify particular issues within organisational procedures that lead to incidents. She also criticised the blame culture a lot of organisations exhibit and called for professionals to avoid generalisations such as ending investigations once blame has been established, be it human error or not following procedure; these errors are not explanations, she said - they demand them.