Root Cause Analysis looks to identify the most basic
causes of incidents that management has the power to fix, and when fixed will
either prevent the incident from recurring or significantly reduce the
consequences of any repeat occurrence.
We approach this through fact-finding, not fault-finding. As stated earlier,
few people go to work with the thought, “Today, I will cut off three of my
fingers,” or “Today, I will cause the company to lose $250,000 in production,”
but these incidents do occur. While shortcuts may have been taken or policies
violated, the people involved felt that they were doing what was acceptable or
perhaps even performing beyond the requirements of the job. When these incidents
occur, the root cause analyst looks at all of the events and conditions that lead
up to the incident and those that followed the event until closure is reached
for that incident. This is an intensive data-gathering time and takes a
substantial portion of the investigation time.
Once the events and conditions surrounding the incident are established, the
events and/or conditions are identified that, had they not occurred, the incident
would not have occurred or the consequences would have been significantly
reduced. Techniques applied here may include Barrier/Safeguards Analysis,
Change Analysis, Critical Human Action Profiles and Equipment Failure Analysis.
These items are then taken through the Root Cause Tree® and the root cause(s)
are determined. Again, the root cause is the most basic cause (or causes) that
can reasonably be identified that management has control to fix and, when fixed,
will prevent (or significantly reduce the likelihood or consequences of) the
Once the root causes have been developed or discovered, corrective actions
are developed to address each of the root causes, either directly or indirectly,
with focus on ensuring that the corrective actions are clearly written, reasonable
from a business sense, timely, and agreeable to all concerned.