UNDERSTAND THE CONCEPT
Root cause analysis examines why an event became possible, including the organizational and technical conditions surrounding it. The last visible action is rarely the whole explanation. Equipment condition, task design, supervision, information quality, workload, and change history may all contribute. An investigation should test explanations against evidence rather than select a familiar answer before the facts are understood.
A useful investigation distinguishes the event sequence, contributing factors, evidence gaps, and recommended actions. Different factors may require different owners. Retraining alone may not address an unclear specification or an unavailable resource. Investigators need appropriate competence and must follow the site's incident procedures, including any requirements for evidence preservation and authority involvement. The learning objective is a defensible explanation that supports prevention, with uncertainty recorded where evidence cannot settle a question.
Questions to take back to your team
- Which evidence supports each proposed contributing factor?
- Have task conditions and organizational decisions been considered?
- Do the recommended actions address the identified causes?
Awareness guide only. Follow applicable requirements, qualified review and your site’s approved procedures. Reading this page does not authorize work or certify competence.
Further reading
Explore the primary references below. Requirements and applicability depend on your organization and jurisdiction.
