Root Cause

Root cause analysis is the basis for all effective preventative measures to protect your organization from operational and regulatory failures.

Everybody talks about root cause, and most likely has a flow chart or 5 why’s primer tacked to the wall in their office but rarely do they have the time to dig deep enough into the issue at hand to develop a real understanding of the reason the failure occurred.

It is all to easy to blame the individual or new process and ignore the organizational or process design issues:

• They did not do the job as intended or as written
• They were not paying attention to the task
• They did not utilize the organizations support resources
• They took it upon themselves to create a workaround for a difficult situation
• The software failed during a particularly difficult operational process
• During implementation no one know why the problem occurred

When systems are designed they need to take all these known and potential unknown factors into consideration to prepare for and protect against negative outcomes, performance decrements, and regulatory failures.

The true measure of an effective system is that it will produce the desired result even when the vagaries of human and advanced technological performance are encountered.

Root cause analysis is the first line of defense for both reactive and proactive system design or redesign. What did happen, what could happen, and why must be understood fully in order to protect the organization from the very real hazards associated with our industry.