World-wide facility incident investigation audits have frequently identified that symptoms and events were stated as the root cause(s). This failure to identify the true underlying root causes often resulted in recommendations that were unlikely to prevent recurrence of the subject incident. To assist companies in correctly identifying the underlying root causes, the author has developed a root cause analysis (RCA) technique that not only systematically drives the RCA to the fundamental underlying management system weaknesses, but also covers occupational safety, health, and environment (SHE); the 20 elements of RBPS, plus some of the additional elements from the authorâs previous paper, such as human factors, and engineering project phases. This paper describes the issues and solutions in detail with examples illustrated from the RCA technique.
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