Root Basic Cause Analysis

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying causes of occupational accidents or incidents. The purpose of investigating and reporting the causes of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers, and the environment. Every root cause investigation and reporting process should include five phases. While there may be some overlap between phases, every effort should be made to keep them separate and distinct. The phases of a root cause analysis are 

The objective of investigating and reporting the cause of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers, and the environment. Programs can then be improved and managed more efficiently and safely. 

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Although there are differences between various predefined trees, the basic method to perform a root cause analysis using the trees is similar whichever tree is used. The following basic steps apply ... 

In this paper, the author attempts to integrate general assmnptions about the structure of safety management into one picture which constitutes the backgroimd for root cause analysis, nowadays the most recommended investigation method. Initial representation of the structure (Fig. 2) is complemented by the definition of the boimdary of internal safety management. The definition e q)loits the tool called Root Cause Map. After the addition of two basic assumptions... 

Basically, it is an innovation of root cause analysis procedure. Again, the cause determination is focused on the identification of multiple causes which are considered to be imderlying system-related ones. The analysis contains the three steps known from the method B ... 

Chapter 3 presents introductory aspects of safety and human factors. Chapter 4 is devoted to methods considered useful to perform patient safety analysis. These methods include failure modes and effect analysis (FMEA), fault tree analysis (FTA), root cause analysis (RCA), hazard and operability analysis (HAZOP), six sigma methodology, preliminary hazard analysis (PFfA), interface safety analysis (ISA), and job safety analysis (JSA). Patient safety basics are presented in Chapter 5. This chapter covers such topics as patient safety goals, causes of patient injuries, patient safety culture, factors contributing to pahent safety culture, safe practices for better health care, and patient safety indicators and their selection. 

In each incident you should ask yourself (1) What happened (2) How did it happen (3) Why did it happen This series of questions is one form of root cause analysis (RCA), a standard procedure in the investigation of incidents in business and industry. The last question is the most important one and you will find you may have to ask and answer this question several times in sequence before you come close to the real or root causes of an incident. RCA generally recommends asking Why five times to get to a fundamental, rather than superficial, cause. Root causes are the basic causes of an incident that can be reasonably identified, that can be controlled, and for which recommendations or lessons learned can be derived. Many times root causes are not immediately obvious, but can be identified from careful inquiry. Once you know the root causes you should be able to develop recommendations or steps to prevent this from happening again. 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying canses of occnpational accidents or incidents. The following should be considered when performing analyses ... 

This chapter provides a brief summary of the root cause analysis process and will help you understand and conduct successful incident investigations. Incident investigation is an important element in an effective safety management system. The basic reason for investigating and reporting the causes of occurrences is to identify action plans to prevent recurrence of incidents. 

Root Causes The most basic causes that can be reasonably identified and fixed, and for which effective recommendations for recurrence can be generated. Tools such as 5-Whys, ABC analysis, and fishbone diagramming can be used to identify root causes for incidents. 

The natural consequence of the causality credo, combined with the Domino model, is the assumption that there is a basic or first cause, which can be found if the systematic search is continued until it can go no further. This is often called the root cause, although definitions differ. In the Domino model, the root cause was the ancestry and social environment, which led to undesirable traits of character. Since this was the fifth domino, it was not possible to continue the analysis any further. Other approaches, particular if they subscribe to some form of abstraction hierarchy, suffer from the same limitation. The type of analysis (which actually is a family of methods) that tries to find the root cause is unsurprisingly called Root Cause Analysis (RCS). 

At its most basic, the process asks three questions, which together provide the framework of a root cause analysis investigation ... 

To be effective the investigation must apply an approach which is based on basic incident causation theories and use tested data analysis techniques. Investigating incidents to determine root causes and make recommendations can be as much an art as a science. Within the industry, best practices in incident investigation have evolved substantially in the last 20 years. This chapter provides a brief overview of some of the more relevant causation theories. 

What oil analysis tells When something occurs that can lead to failure— root cause conditions When an early-stage fault exists that is otherwise going unnoticed for example, abnormal wear What is the nature of observed problem Where does it come from How severe is it Can it be fixed That a machine is basically worn out and needs to be fixed or replaced What caused the machine to fail Could it have been avoided ... 

Initiating event In hazard analysis, an event could be the occurrence of a deviation which may lead to an accident. So, the initiating events are the causes for which there is the process deviation. The initiating events may be or may not be the most basic underlying root-causes, but are the results of the root causes. According to CCPS there are three types of initiating events or causes ... 

The Circle Used to depict a basic event in the FTA process. It can be a primary fault event (i.e., the first in the process to have occurred) and, therefore will require no further development. Use of the circle symbol offers the analyst some flexibility. A causal chain could conceivably become quite extensive. Many times, the analyst will obtain sufficient casual information from analysis of higher level events in the chain. Therefore, in order not to waste valuable time and resources analyzing a single event to its lowest possible level, the analyst can label a particular event as basic, using the circle symbol indicating that no further development is required. For this reason, the symbols of the fault tree places the circle at the base of the tree (i.e., a basic event). The basic event is also often referred to as a root event or root cause, for obvious reasons. 

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