Pure Root Cause Analysis


Round the world, there is much ambiguity over what is meant by ‘Root Cause Analysis’ (RCA), and a variety of explanations and definitions appear on the Internet, on a regular basis.  So, we at Kelvin set about developing a straightforward system of tricks, tips and rules, to enable anyone to have a go at developing their own analysis.  What’s more, we have made it quite clear where RCA stands in the Investigative process, and how it enhances a final Investigation Report.  We have called it ‘Pure Root Cause Analysis’.

So, what are the details, we hear you ask?  Well, you need to come to one of our new 1-day Root Cause Analysis courses, which will be advertised shortly on our Website.  But in the meantime, let’s just clarify a few points, to whet your appetite.

1. Pure Root Cause Analysis is, fundamentally, a Logic-flow Diagram, showing how all the contributing factors lead to an incident: the Immediate, Underlying and Root Causes.  These are linked vertically by using the word ‘Why’, and horizontally, by using as many ‘ands’ and ‘ors’ as are required.  There is no rule about the number of steps – no 5-Whys – you just use as many as are appropriate.  Which dodges a major question: What do you mean by ‘appropriate’?  You’ll have to come to one of our courses to find out about that!

2. The RCA is part of the final Report.  It acts as a précis or summary, or a proof of the incident, and all the ‘causal factors’ which contributed to it.  It should stand on its own, and not require embellishment or explanation. 

3. It acts as a working ‘canvas’ on which to consider all the possible ‘fixes’ which might be employed to prevent the same, or similar incidents happening again.  It allows comprehensive barrier analysis to be undertaken in a straightforward and simple way, and this is hugely important.

4. Our RCA system is easy to understand, and has very few straightforward rules.  This is good.  But the downside is that many assume that simple systems are only useful for ‘simple’ incidents; that major incidents require a much more sophisticated system of analysis.  This could not be further from the truth.  As Leonardo da Vinci said, a long time ago, “Simplicity is the ultimate sophistication”.  We are very happy with that concept.

Why not join us on one of our courses to learn more, and to perfect your skills?

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