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What Is Root Cause Analysis?

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 problem's recurrence.

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.

 
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