Field work

How is a root cause analysis carried out?

Write the event on a timeline and keep asking "why was this possible" at each step until you reach a cause that sits in the system rather than in a person's behaviour. If the analysis ends at "carelessness", it has stopped early: look for the condition that made carelessness possible.

Start with the timeline

First write what happened, from evidence and without interpretation: time, place, who was where, which equipment was in what state. Then for each fact ask "why was this possible" and let the answers branch. Looking for a single root cause is wrong in most events; record separately which barriers were absent and which were present but did not work.

Two common mistakes

The first is ending the analysis at a person: "the worker was careless". That is not a finding, it is where the explanation stopped. The second is closing the corrective action with "training will be provided"; training is ineffective against a cause that was never about missing knowledge.

An analysis is not complete until the finding is tied to a corrective action and that action to a verification. In Optifora the incident record, the barrier inventory and the task list sit in the same chain.

Manage this in Optifora

Optifora is not a single program but a compliance platform assembled from modules. The catalogue states which module is ready today and which is on the roadmap.

See what Optifora is