Use root-cause thinking to identify system contributors and corrective actions.
The event summary names a person but not the conditions that shaped the action. Define the event, identify contributing factors, find system causes, and choose corrective actions that reduce recurrence. The trap is stopping at the first human action because it feels concrete and fast. Step 1 State the event neutrally: wrong procedure version used during setup. Neutral wording keeps the review open to system contributors. Step 2 Map contributors: old copy at station, tool far away, change not briefed. Multiple weak conditions can align behind one visible action. Step 3 Design actions: remove obsolete copies, control versioning, place tool…
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