James Reason´s Swiss Cheese Model of Accidents: https://pbs.twimg.com/media/EkklF9WU8AAwd7Q.jpg ^a39a3f

(p. 208)

On root cause analysis

Why does the root cause analysis stop as soon as a human error is found? (p. 164)

People do tend to blame themselves when they do something that, after the fact, seems inexcusable. “I knew better”, is a common comment by those who have erred. But when someone says, “It was my fault, I knew better”, this is not a valid analysis of the problem. That doesn´t help prevent its recurrence (p. 167).

Double Diamond Model of Design

The double diamond model of design: a divergence and convergence process for both finding the right problem and finding the right solution. (p. 22)