Step 2. Why did it happen? - AnalysisIt’s important to remember in this step that every effect has causes (plural). People may try to identify the single cause of an issue, what is commonly referred to as the “root cause.” There is not a single cause to any incident. There are causes.
The fire triangle illustrates there is no single cause for a fire; there are causes – heat, fuel and oxygen. Controlling any one of these causes will reduce the risk of the fire. Most people mistakenly believe oxygen is a “contributing factor” to a fire, meaning on it’s own it can’t produce a fire. In reality, there is no difference between a contributing factor and a cause. A cause, by definition, is required to produce an effect. Oxygen is required for fire; it is therefore a cause of fire. On its own, oxygen will not produce a fire. Neither will heat nor fuel. Fire requires all three causes, heat, fuel and oxygen. An effect requires all of its causes. The most effective way to communicate the causes of an incident is in a visual format. The cause-and-effect analysis should start with the impact to the overall goals and then ask Why questions moving to right. Why questions take us backwards in time through the failure. Visually breaking down the cause-and-effect relationships as the information is collected is the simplest way to document the investigation and its supporting evidence. The focus of this step is an accurate cause-and-effect analysis to a sufficient level of detail. It is during this analysis step that detail is added to the timeline, the diagrams and photographs are utilized and the specific steps of the processes that were in place are identified. These additional tools are used to collect and organize all available information to ensure the cause-and-effect analysis is accurate. The facilitator is typically moving back and forth between the different tools and the cause-and-effect analysis as information is collected. A complete analysis starts with the negative impact to the overall goals and captures the causes with supporting evidence. |