Root Cause Analysis: Unveiling the Secrets of Effective Incident Investigation

Root Cause Analysis: Unveiling the Secrets of Effective Incident Investigation

Welcome to our comprehensive guide on Root Cause Analysis (RCA) and best practices for conducting an incident investigation. In today’s dynamic world, workplace safety and problem-solving are crucial for organisations across industries. RCA provides a systematic approach to identifying the underlying causes of incidents, enabling organisations to implement effective corrective measures. 

In this blog, we will explore the intricacies of RCA, discuss its importance, and provide actionable insights for successful incident investigations. So, let’s dive in!

The Importance of Root Cause Analysis in Incident Investigation

Incident investigations are essential for maintaining workplace safety, preventing accidents, and enhancing operational efficiency. Root Cause Analysis plays a pivotal role in this process. By delving deep into the underlying causes of incidents, RCA enables organisations to identify systemic issues and implement effective corrective actions. It helps in mitigating risks, reducing recurring incidents, and ensure a safer work environment for employees.

The Three Levels of Root Causes

In RCA, failures are often categorised into three levels.  Each level offers valuable insights into the different factors that play a role in incidents. The three levels are:

Physical Causes

Physical causes refer to factors that are directly observable and tangible within a system or environment. These causes often manifest as immediate failures that directly impact incidents. Examples of physical causes include equipment malfunctions, structural deficiencies, material defects, or environmental conditions. By identifying physical causes, organisations can gain valuable insights into the specific elements that need to be addressed to prevent similar failures. In a manufacturing setting, a physical cause could be a faulty machine component leading to product defects. In terms of workplace safety, physical causes may involve slip hazards, machinery malfunctions, or improper storage of hazardous materials.

Human Causes

Human causes encompass errors, actions, or behaviours of individuals or groups that contribute to failures or incidents. These causes are often linked to communication breakdowns, inadequate training, lack of awareness, fatigue, distraction, or complacency. Understanding human causes is critical in root cause analysis as it highlights the need to address factors related to human performance and improve organisational systems and practices. This can involve implementing enhanced training programs, establishing clearer communication protocols, standardising procedures, and fostering a culture of accountability, continuous learning, and open communication. For example, in a transportation context, a human cause might be a driver’s fatigue leading to a vehicle accident. In a healthcare setting, a human cause could involve a miscommunication between medical staff resulting in a medication error.

Latent Causes

Latent causes, also known as organisational or systemic causes, refer to underlying factors or conditions that contribute to failures. Unlike physical causes, latent causes are not immediately apparent but have a systemic influence on incidents or problems. These causes can be related to organisational culture, management systems, inadequate policies, insufficient resources, or ineffective procedures. Analysing latent causes requires a deeper understanding of the broader organisational context and the factors influencing decision-making, resource allocation, and work processes. Addressing latent causes often involves making systemic changes to prevent recurring failures and foster a culture of safety and continuous improvement.

By considering physical causes, human causes, and latent causes in root cause analysis, organisations can gain a holistic understanding of the factors contributing to failures or incidents. This comprehensive approach allows for the implementation of effective corrective actions that address the specific elements within each cause category, leading to improved performance, reliability, and safety.

Key Steps in Conducting a Root Cause Analysis

Key Steps in Conducting a Root Cause Analysis

To conduct an effective RCA, organisations should follow a systematic approach. Let’s explore the key steps involved in conducting a root cause analysis:

Step 1: Define the Problem and Establish the Scope

Defining the problem and establishing the scope are crucial initial steps in any incident investigation. Clearly articulate the incident, its impact, and the desired outcome of the investigation. Define the scope by identifying the boundaries of the investigation and setting realistic goals.

Step 2: Collect Data and Identify Possible Causes

Gathering relevant data is essential for a comprehensive RCA. Collect information from various sources, such as incident reports, witness accounts, equipment logs, and relevant documentation. Utilise interviews, surveys, and observations to gather additional insights. Identify possible causes by analysing the data and categorising them into contributing factors.

Step 3: Analyse and Determine the Root Causes

In this step, conduct a thorough analysis of the identified causes to determine the incident’s root cause(s). Use techniques like the 5 Whys, Fishbone Diagrams, or Fault Tree Analysis to explore causality and uncover deeper underlying factors. Look beyond immediate causes and focus on systemic issues that contribute to incidents.

 Step 4: Develop Corrective Actions and Implementation Plans

Once the root causes are determined, it’s crucial to develop effective corrective actions and implementation plans. Brainstorm potential solutions, considering both short-term and long-term measures. Prioritise actions based on their potential impact and feasibility. Clearly define responsibilities, timelines, and resource requirements to ensure smooth implementation.

Step 5: Monitor and Evaluate the Effectiveness of Actions

Implementing corrective actions is not the end of the process. Continuous monitoring and evaluation are vital to measure the effectiveness of the implemented actions. Define key performance indicators (KPIs) to track progress and assess the impact of the implemented measures. Regularly review the data, collect feedback, and make adjustments if necessary.

The 5 Whys Technique in Root Cause Analysis

The 5 Whys technique is a powerful tool used in root cause analysis to identify the underlying causes of a problem or incident. It involves repeatedly asking “Why?” to drill down to the core cause of the issue. By uncovering multiple layers of causality, the 5 Whys technique helps in identifying the root cause rather than just addressing the symptoms.

The process involves asking “Why?” after each answer, up to five times or until the root cause becomes clear. The number of iterations may vary depending on the complexity of the problem. Let’s understand the steps involved in using the 5 Whys technique:

Step 1: Define the Problem

Start by clearly defining the problem or incident you are investigating. This ensures focus and clarity throughout the analysis.

Step 2: Ask the First “Why?”

Begin by asking why the problem occurred. The answer provided will be the first cause or reason behind the problem. It is essential to provide a specific and factual response.

Step 3: Ask Four More “Whys?”

For each answer obtained, ask “Why?” again, delving deeper into the causal factors. Continue this process until you have reached the root cause. Remember to ask why for each successive answer, ensuring a logical progression.

Step 4: Identify the Root Cause

The root cause is the underlying factor that, when addressed, will prevent the problem from recurring. It is often the final “Why?” in the sequence of questions. This root cause is crucial in developing effective corrective actions.

It is important to note that the 5 Whys technique should not be limited to just five iterations. Depending on the situation, you may need to ask more or fewer “Whys” to reach the true root cause.

Example of the 5 Whys

Here’s an example of using the 5 Whys technique to analyse a warehouse forklift accident:

Problem: A forklift collided with a storage rack, causing damage to both the rack and the forklift.

1st Why: Why did the forklift collide with the storage rack?

Answer: The forklift operator lost control.

2nd Why: Why did the forklift operator lose control?

Answer: The forklift’s brakes failed to respond.

3rd Why: Why did the forklift’s brakes fail to respond?

Answer: The brake system was not maintained properly.

4th Why: Why was the brake system not maintained properly?

Answer: The maintenance schedule for the forklift was not followed.

5th Why: Why was the maintenance schedule not followed?

Root Cause: There was no proper documentation and tracking of maintenance activities.

In this example, the root cause of the warehouse forklift accident was the lack of proper maintenance and documentation of the forklift’s brake system. By addressing this root cause, the organisation can implement corrective actions such as:

  1. Implementing a robust maintenance schedule for all forklifts, including regular brake system inspections and maintenance.
  2. Establishing proper documentation and tracking systems for maintenance activities to ensure accountability and adherence to schedules.
  3. Providing training and awareness programs for forklift operators on the importance of reporting any equipment issues promptly.

Addressing the root cause helps prevent similar accidents in the future and promotes a safer warehouse environment for employees and equipment.


Root Cause Analysis is a powerful methodology for conducting incident investigations and driving workplace safety. By systematically identifying and addressing root causes, organisations can prevent future incidents, enhance operational efficiency, and create a safer work environment. Remember to define the problem, collect data, analyse causes, develop corrective actions, and monitor their effectiveness. Implementing these best practices will help you unlock the true potential of Root Cause Analysis and make a positive impact on workplace safety.

By prioritising problem-solving, implementing effective corrective measures, and embracing a culture of continuous improvement, organisations can ensure a safer, healthier, and more productive work environment for all. Start your journey into Root Cause Analysis today, and reap the benefits of enhanced safety and operational excellence.

Frequency Asked Questions 

How can Root Cause Analysis be effectively implemented?2023-06-05T09:56:00+09:30

To implement Root Cause Analysis effectively, consider the following steps:

  • Clearly define the problem and establish the scope of the analysis.
  • Collect relevant data and information from multiple sources.
  • Utilise appropriate RCA techniques to identify and analyse potential causes.
  • Determine the root causes by systematically drilling down to the fundamental factors.
  • Develop and implement corrective actions and monitor their effectiveness.
  • Establish a culture of continuous improvement and learning from incidents.
What are some common techniques used in Root Cause Analysis?2023-06-05T09:52:33+09:30

Various techniques can be used in Root Cause Analysis, including:

  • 5 Whys: Repeatedly asking “Why?” to uncover deeper causes.
  • Fishbone Diagram (Ishikawa Diagram): Identifying potential causes across categories like people, processes, equipment, environment, and materials.
  • Fault Tree Analysis: Mapping out the causes and events leading to a specific outcome using logic diagrams.
  • Pareto Analysis: Identifying the most significant factors contributing to the problem using the 80/20 principle.
  • Change Analysis: Investigating changes or events leading up to the problem.
What are the benefits of conducting Root Cause Analysis?2023-06-05T09:51:40+09:30

Conducting Root Cause Analysis brings several benefits, including:

  • Prevention of future incidents or problems.
  • Improved workplace safety and risk mitigation.
  • Increased operational efficiency and productivity.
  • Enhanced decision-making based on data-driven insights.
  • Development of effective corrective actions.
  • Reduction of costs associated with recurring issues.
What is Root Cause Analysis?2023-06-05T09:50:48+09:30

Root Cause Analysis is a systematic approach used to identify the underlying causes of problems, incidents, or failures. It involves digging beyond the immediate or surface-level causes to uncover the fundamental factors that contribute to the issue.

What can a Root Cause Analysis (RCA) be used for?2023-06-05T09:49:58+09:30

Root Cause Analysis (RCA) is not limited to incident investigation and problem-solving. It can be applied to various areas and industries to drive improvement and enhance decision-making. Here are some additional uses of RCA:

  • Process Improvement: RCA can be used to identify bottlenecks, inefficiencies, and sources of waste in business processes. By analysing the root causes of process issues, organisations can streamline operations, reduce costs, and improve overall efficiency.
  • Quality Control: RCA helps in identifying the root causes of quality issues, defects, or customer complaints. By addressing these root causes, organisations can enhance product or service quality, improve customer satisfaction, and prevent recurring quality issues.
  • Risk Management: RCA plays a vital role in identifying and mitigating risks. It helps organisations understand the underlying causes of potential risks and develop effective risk management strategies. By addressing root causes, organisations can minimise the likelihood and impact of future risks.
  • Safety and Compliance: RCA is widely used in the field of workplace safety and regulatory compliance. It helps in investigating accidents, incidents, or violations to determine the root causes and develop corrective actions to prevent similar occurrences. RCA assists in creating a safer work environment and ensuring compliance with safety regulations.
  • Customer Experience: RCA can be applied to analyse customer experience issues, such as poor service, customer dissatisfaction, or high churn rates. By uncovering the root causes of these issues, organisations can implement improvements that lead to enhanced customer satisfaction and loyalty.
  • Product Development: RCA can be used during the product development lifecycle to understand design flaws, performance issues, or customer feedback. By identifying and addressing the root causes, organisations can improve product reliability, functionality, and customer acceptance.

DIGI CLIP mobile forms – What Do We Do?

DIGI CLIP mobile forms is an easy-to-use inexpensive digital checklist & inspection app and cloud-based software. DIGI CLIP is used across different industries to capture safety and compliance data and other information to help improve safety, compliance and operational efficiencies.

DIGI CLIP will allow you to remove paper reporting from your business – no more lost, late missing or illegible checklists. The DIGI CLIP mobile app allows images, comments and digital signatures to be added to checklists from a phone or tablet.

DIGI CLIP has a Form Library where you can access all of your checklists, inspections and more ready for use. All checklists and inspections can be edited or updated to meet your risk and operational requirements.

DIGI CLIP also has a safety management module called Safety Tracker. Safety Tracker is our incident and hazard reporting and management software application that adds to DIGI CLIP mobile forms. Incidents and hazards are reported via the DIGI CLIP app or directly on the cloud-based software. Incident and quality Investigations and hazard assessments are completed on templates provided by DIGI CLIP and corrective and closeout actions are tracked by the cloud-based software.

Follow this link if you want to know more about what we do and how we can help or send us a message.

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Disclaimer: The information contained in this article is for general informational purposes only. It is not intended to provide legal, financial, or other professional advice, nor is it intended to replace the advice of a qualified professional. The author and publisher disclaim any liability for any direct, indirect, or consequential damages arising from the use of or reliance on the information provided in this article. Readers are advised to seek the advice of a qualified professional for any specific concerns or questions related to their business operations or compliance with relevant regulations.
By |2023-06-05T12:31:59+09:30June 5th, 2023|Compliance, Safety, WHS, Workplace Safety|0 Comments

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