Monday Accident and Lessons Learned: CNN Reports “Series of Errors” in Jet Collision – Root Cause Analysis Seldom Finds Just One Root Cause
A report at the CNN web site includes the following quote:
“The tower instructions reported by Folha may have been the first of a series of problems that led to the crash.”
The term “root cause analysis” can be confusing to some. Why? Because they may believe that it is possible to find a single “root cause” for a major accident or incident.
In TapRooT® Courses we train investigators that major accidents are caused by a series of events. These events have causes. Usually several of these causes could have been prevented, or significantly reduced the consequences of, the accident and thus are labled “causal factors”. We train investigators to analyze these causal factors using the Root Cause Tree® to find the fixable root causes that can be corrected to prevent future repeats of the causal factors and thus the accident.
Thus root cause analysis is actually a way to find many – not just one – ways to improve performance and prevent accidents.