Root Cause Analysis Literature Review

Chapter 2

2. Literature Review
Root causes analysis is simply a tool designed to help incident investigators describe what happened during a particular incident, to determine how it happened and to understand why it happened.
The definition of a root cause varies between authors and root causes methodologies, with different ‘levels’ of causation being adopted by different systems. Figure 1 illustrates the different levels of cause that can be ascribed to an incident. The root causes lie at level 1 which inevitably influence the effectiveness of all the risk control systems and workplace precautions that exist at levels 2 and 3.
The most useful definition identified to date is the definition used by Paradies and Busch (1988), that is:
The most basic cause that can be reasonably identified
And that management has control to fix
This definition will be used for this review. It contains three key elements:
Basic Cause: Specific reasons as to why an incident occurred that enable recommendations to be made which will prevent recurrence of the events leading up to the incident.
Reasonably Identified:
Incident investigation must be completed in a reasonable time frame. Root causes analysis, to be effective, must help investigators to get the most out of the time allotted for investigation.
Control to Fix: General cause classifications such as ‘operator error’ should be avoided. Such causes are not specific enough to allow those in charge to rectify the situation.