Event

In common terms, an event is a finite change in the state of an entity during a finite timeframe. The variability of the factors — the nature and magnitude of the state change, the length and suddenness of the timeframe — can affect the interpretation of the word significantly for any given situation (e.g., micro-events, […]

Top 5 Reasons for Failed Root Cause Analysis

Root cause analysis is one of the best ways to solve difficult or significant problems, but sometimes, root cause analysis efforts fail because the corrective actions weren’t effective. If the original problem happens again, or the needed improvements haven’t materialized, or a new problem arises because of the corrective actions, you need to figure out what happened […]

RCA Article Guide

There’s a large number of root cause analysis articles on this site. If you’re already a cause analysis pro, then you can probably just pick through the main RCA Articles list and find things that might interest you. However, if you’re new to root cause analysis, then that probably isn’t going to be a great way to […]

Systems Thinking, Complexity, and Root Cause

I’m getting so very tired of safety/accident researchers claiming that root cause analysis is an invalid, blame-focused practice that ignores systems and complexity. Most root cause investigators that I know are pretty well oriented towards process, organization, and system issues as the fundamental sources underlying problems and accidents… and even some of our simplest analysis […]

Evaluating the Quality of a Root Cause Analysis

The quality of a Root Cause Analysis (RCA) and its Corrective Action Plan (CAP) should be evaluated many times over its lifecycle (i.e., from initial problem or event, through to final verified and sustainable improved state). Reviews occurring earlier in the lifecycle can really consider only the apparent quality of the investigation/analysis effort itself; these early reviews […]