Root cause analysis

Root cause analysis is the process of learning from consequences. The consequences can be desirable, but most root cause analysis deals with adverse consequences, e.g., the so-called d-words: death, damage, delay, disruption, dollars (of loss), disgrace, discredit, discharges (to the environment), etc.

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The generally accepted principles of root cause analysis include:

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• Do all reasoning from solid evidence.
• Determine what influenced the consequences, i.e., determine the necessary and sufficient influences that explain the nature and the magnitude of the consequences.
• Establish tightly linked chains of influence.
• At every level of analysis determine the necessary and sufficient influences.
• Whenever feasible drill down to root causes.
• There are always multiple root causes.

The Apollo Process ;

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The Apollo process is a 4-step method for facilitating a thorough incident investigation. The steps are:

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• Define the Problem: What do we want to prevent from recurring? When and where did it occur? What is the significance of the problem?
• Analyze Cause and Effect Relationships: Once the problem is defined, we need to understand the causes and how they interact with one another.
• Identify Solutions: Solutions are specific actions that control causes.
• Implement the Best Solutions: The best solutions are those that prevent problem recurrence, are within our control, and meet our goals and objectives.
 
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