Tag Archives: risk

Root Cause Analysis – Large or Small Events?

Root Cause Analysis (RCA) can be applied to events of any size or significance. However, it's usually applied to large events, i.e. those with serious consequences. Even so, it can and should be applied to smaller events as well. Statistically, smaller events are more likely to occur than larger events. Thus, application of RCA to small events may identify many significant opportunities for improvement.
Continue reading

The Fortunate Near-Miss Event

What do you consider to be an event worthy of investigation? Do you look only at events that had serious consequences, or do you consider less serious events as well? What about near-misses?

I've recently been involved in the investigation of a near-miss event. By near-miss (or near-hit?), I mean an event that almost happened -- an event that terminated one step before a serious consequence was experienced. As is often the case, the event sequence was a seeming string of coincidences. It ended without consequence simply because there was nobody at the event location to be injured.
Continue reading