Getting to the Root: A Roadmap to Root Cause Analysis Methods

Theo Ashworth

Every incident has a story. And here's the awkward bit: most of the time, the first explanation people reach for isn't the real one.

Nell Harding

Welcome to Getting to the Root, Root Cause Analysis Methods. I'm Nell Harding.

Theo Ashworth

And I'm Theo Ashworth. This show is for safety professionals, engineers, quality managers, operational leaders, anyone who's tired of fixing the same problem twice. Nell, you've seen that, haven't you? The corrective action that gets signed off, and then three months later the same thing happens again.

Nell Harding

Constantly. And usually the first explanation stops at a surface symptom, or at someone on the front line. An operator made an error, so we retrain the operator. Done. But if the person before them could have made the same mistake, then it wasn't really about that person, was it?

Theo Ashworth

It's like mopping a floor under a leaking pipe. You can mop beautifully, but the floor's going to be wet again tomorrow. Real prevention means looking past the immediate action to the conditions around it: systemic factors, organisational blind spots, latent failures that were sitting there long before anyone made a mistake.

Nell Harding

So this episode is the road map. Sixteen episodes, and each one takes a single method and breaks it down. Where it came from, how it works step by step, when it shines, where it falls short, and what it looks like on a real incident.

Theo Ashworth

And we've deliberately built it as a ladder. We start with simple tools you could use in a team meeting tomorrow, and we climb to the investigation grade systems used in aviation, mining, oil and gas, and healthcare.

Nell Harding

Right, so walk us up the ladder. Where do we start?

Theo Ashworth

Episode one is the 5 Whys. It was born at Toyota, and it traces a linear chain of cause and effect. The trick we dig into is avoiding the dead end of human error, where the chain stops the moment someone's name appears. Episode two is the Ishikawa, or fishbone, diagram. That's about brainstorming many contributing factors across structured categories, the 6Ms or the 4Ps, and then going to the Gemba to check which suspects hold up.

Nell Harding

Episode three is Pareto analysis. The idea of separating the vital few from the useful many, using the 80/20 rule, with frequency and severity weighting, so you know where to spend your effort. Then episode four moves into heavy industry with ICAM, which applies James Reason's model across four tiers, from failed defences all the way up to upstream organisational factors.

Theo Ashworth

Episode five is AcciMap, Rasmussen's vertical systems thinking. It maps political, regulatory and corporate drift, and we look at the Walkerton disaster as the example. Episode six turns things around. FMEA is proactive. You rate severity, occurrence and detection, and use Action Priority to prevent failures before the incident ever happens.

Nell Harding

Episode seven, Fault Tree Analysis. Boolean logic with AND gates and OR gates, starting from a catastrophic top event and working backwards to the basic failure events. And episode eight is the Swiss Cheese Model, James Reason's foundational distinction between active failures and latent organisational conditions.

Theo Ashworth

Which sets up episode nine, HFACS. Nineteen categories of human factors across four tiers, and it takes Reason's model and turns it into something you can audit. Episode ten is Bow Tie analysis, where you visualise the preventative barriers on one side and the mitigative barriers on the other, flanking a top loss of control event.

Nell Harding

Episode eleven is TapRooT®. It pairs SnapCharT® timelines with root cause decision trees, and the aim is to eliminate frontline blame. Episode twelve combines Change Analysis and Barrier Analysis. One evaluates deviations against a baseline, the other tests whether physical, procedural or administrative barriers failed.

Theo Ashworth

Thirteen is Kepner Tregoe Problem Analysis. It isolates a deviation under operational pressure by contrasting what IS and what IS NOT across four dimensions. Fourteen is 8D, Ford's eight disciplines, running from D0 emergency containment right through to D8, systemic organisational prevention.

Nell Harding

Fifteen is Apollo RCA, from Dean Gano. The principle is that every effect needs at least one action and one condition, linked by verified evidence. And that brings us to episode sixteen, which for me is the payoff.

Theo Ashworth

Choosing the Right RCA Tool. Matching the rigour of the method to the complexity of the problem, and then judging your fixes using the NIOSH hierarchy of controls. Because by the end of the series, you won't just know the methods. You'll know which one to reach for, and why.

Nell Harding

Now, a word on who's presenting the series.

Theo Ashworth

Getting to the Root is presented by Dr Wayne M Sundborg and Industrial Accident Investigators Limited. Dr Sundborg is a member of the Institute of Industrial Accident Investigators, and he brings more than forty years of international experience across four continents.

Nell Harding

He's led more than 500 high profile investigations, including 211 fatal incidents, across oil and gas, petrochemicals, power generation, mining, and heavy construction. That's the field experience sitting behind these methods.

Theo Ashworth

Industrial Accident Investigators Limited describes itself this way: Trusted industrial accident investigators with global reach. Root cause analysis, expert reporting, full regulatory compliance.

Nell Harding

If you'd like to get in touch, the address is 71 to 75 Shelton Street, Covent Garden, London, W C 2 H 9 J Q, United Kingdom.

Theo Ashworth

The website is www dot industrialaccidentinvestigators dot co dot uk, and the email is wayne at industrialaccidentinvestigators dot co dot uk.

Nell Harding

By phone in the United Kingdom, call plus 44, 0, 203 949 8366, or plus 44, 0, 7498 682913. From Asia Pacific, it's plus 66, 09 343 94500. And in the Middle East, plus 968, 77 434 107.

Theo Ashworth

So that's the road map. Next time, we start at the bottom rung with the humble 5 Whys, and see how far a simple question can take you.

Nell Harding

And how often it stops too early. See you in episode one.