Things are winding down a little work wise for me, but like everyone else I'm pressed for time. So for this month I've cheated a little on my newsletter and am highlighting an article about root cause analysis.

As you are receiving this, I'll be in Disneyworld with my teenage grandkids. They've done all the planning, and then their parents invited themselves along too.

Should be a great trip! Back at work on October 17th.

Although there is substantial debate on the definition of root cause, we use the following:

1. Root causes are specific underlying causes.

2. Root causes are those that can reasonably be identified.

3. Root causes are those management has control to fix.

4. Root causes are those for which effective recommendations for preventing recurrences can be generated.

Root causes are underlying causes. The investigator's goal should be to identify specific underlying causes. The more specific the investigator can be about why an event occurred, the easier it will be to arrive at recommendations that will prevent recurrence.

Root causes are those that can reasonably be identified. Occurrence investigations must be cost beneficial. It is not practical to keep valuable manpower occupied indefinitely searching for the root causes of occurrences. Structured RCA helps analysts get the most out of the time they have invested in the investigation.

Root causes are those over which management has control. Analysts should avoid using general cause classifications such as operator error, equipment failure or external factor. Such causes are not specific enough to allow management to make effective changes. Management needs to know exactly why a failure occurred before action can be taken to prevent recurrence.

We must also identify a root cause that management can influence. Identifying "severe weather" as the root cause of parts not being delivered on time to customers is not appropriate. Severe weather is not controlled by management.

Root causes are those for which effective recommendations can be generated. Recommendations should directly address the root causes identified during the investigation. If the analysts arrive at vague recommendations such as, "Improve adherence to written policies and procedures," then they probably have not found a basic and specific enough cause and need to expend more effort in the analysis process.

Root Cause Analysis for Beginners (pdf of full article)

Investigation Kit

Kit Details (pdf article)

Pricing and Ordering Information

E-Learning Programs

My E-Learning programs are available without cost to newsletter subscribers. Each takes about an hour to complete.

Incident Investigation
The Incident Investigation program provides an overview or introduction to the process.

Collision Scene Management
The Collision Scene Management session would benefit drivers who may have to gather collision scene evidence.

Alberta Occupational Health and Safety Act

Convictions - Alberta Occupational Health and Safety Act

Charges - Alberta Occupational Health and Safety Act