![]() Regardless of the tools you use, the final product of the analysis phase should be a finite set of root causes for the problem/ event that show why it was inevitable. Jumping too early into what could be risks obscuring your vision of what is. The future must not enter into the equation. However, analysis is about discovering conditions that exist now or existed in the past. It is all too easy to let desired corrective actions colour your perceptions of an incident's causes. " be considered during the analysis phase. The point of any analysis tool is to provide insight, and in some situations, one tool may be vastly superior to another.įinally, do not let questions like "how can I fix this?. For example, if you're not getting any insight using Barrier Analysis, switch over to Change Analysis. Each has its own strengths and weaknesses, and preferred realms of application. Many tools are available to aid the analysis phase. Mentally place yourself within the incident, watch events unfold, and then determine if the system's values were, for example: correct but inadequately applied, insufficient to prevent the incident, or incorrect such that the system's values actually created (or contributed to) the incident.ĭon't get too caught up in the mechanics of the analysis tool being used. The values of the system (purpose, rules, culture, etc.) can now be used to compare what actually happened against what should have happened, at any point during the incident.ĭuring the analysis phase, do not let yourself fall into the trap of believing that the values of the system are always correct! You are not just analyzing the incident itself, but also the system that created it. This is when you take the purely factual representation of the incident and view it within the context of the system (or organization) that created it. The purpose of the analysis phase is to discover reasons that explain WHY an incident occurred. Only after you've reached this point should you progress to the next phase, Analysis. This representation should then be thought of as a complete script or plan for reproducing the incident in detail. If some facts were not available, and theory (backed up by testing) had to be used instead, ensure this is clearly evident in the representation of the incident. ![]() Regardless of the tools you use, the final product of the investigation phase should be a factual representation of the incident. Attempt to reconstruct the event using plausible scenarios and then perform controlled tests to confirm or deny the most likely explanations. Consider secondary sources that may not be conclusive, but could provide enough circumstantial evidence to guide further investigation. There may be times when required facts simply aren't available - critical evidence was destroyed in the process, or there were no witnesses to a critical event. Jumping too early into what should have happened will obscure your vision of what did happen. Facts exist regardless of what we think or feel about them. Investigation deals with facts in a value-neutral manner.ĭuring the investigation phase, if you find yourself using words like "not", "should", "error", "incorrect", "inappropriate", etc., STOP! You are injecting value judgements into a practice that requires absolute neutrality. During investigation, we are not concerned with what didn't happen, or what should have happened - the only concern is what actually happened, without any judgement of value. The purpose of the investigation phase is to discover facts that show HOW an incident occurred. I've designated these phases Investigation, Analysis, and Decision. ![]() so different that they should always be kept distinctly separate. More importantly, these three phases are very different from each other. In reality, however, there are just three main phases we need to be concerned about. I've seen some methodologies that break down the RCA process into as many as a dozen different steps. Root Cause Analysis (RCA) is generally conducted in several phases.
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