The root cause of a failure, incident or accident has been defined as the most basic cause that can reasonably be identified and that management has control to fix. In this context Root Cause Analysis can be described as a tool designed to help the investigator determine in a reasonable amount of time, exactly what incident occurred and how and why it occurred, allowing management to put control measures in place to prevent re-occurrence.
A key aspect of Root Cause Analysis is repeated review of the suspected cause to determine if it is indeed the root cause or if there are other underlying causes. There are typically three levels to which the cause of an incident may be ascribed, the resources level, i.e. equipment and/or personnel, the process level i.e. the routine processes and procedures involved in completing the given task and the policy level, i.e. the planning, organisational control and performance reviews of the organisation. A Root Cause Analysis which assigns the cause to the first two levels, i.e. resources and processes rather than the policy level has probably failed to identify the true root cause and risks a repeat of the incident or accident.
There are generally three key component needed for an effective Root cause Analysis:
- A method to step through the sequence of events leading to the incident. This could be a flow chart or a simple bulleted list
- A method for identifying the active failures and conditions in the incident sequence. E.g. a recent change in the process that wasn’t risk assessed or for which inadequate training was provided
- A method for systematically investigating the management and organisational factors that allowed the active failure to occur, e.g. a culture within the laboratory or organisation of insufficient attention being paid to matters of Health and Safety
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