Have a look at www.thinkreliability.com who have lots of useful case studies and archived webinars using their own version of RCA plus 5 whys. Using their own 'cause mapping' technique can provide a single A3 sheet visually summarising everything to do with an incident - including solutions. No special software or array of shapes and types of arrows etc - I use post-it notes initially, and Excel can be used (they show how) to do a smart version. If I need to - keeps it simple and quick. The US accent can grate a little, but the process is logically mapped out. Start with their Titanic case study, see how they build it up in a webinar, and then look at a few other examples; they range from the financial crash (USA), to Concord. Anything where something has, or could have, gone wrong - doesn't have to be H&S specifically. They make the point (in one of their webinars) that there are lots of formal analysis processes, FTA, FMEA, RCA etc (the list was very long!) but they all boil down to analysing "what went wrong" and then "what can we do about it".

I went on an 4 day IOSH approved Accident Investigation and Evidence Gathering course last year. When I raised the subject of RCA I was told by the course provider that in contemporary investigation processes RCA is dead. In short, the focus is on latent issues associated multi-causality.

I would disagree with ther comment. RCA is extremely important in testing percieved (or required) causes. It also demonstrates how accidents are casued by the actions and decisions of others, some of which may be very remote from the process that casued the injury.

You are entitled to your opinion of course. I have always disliked the term Root Cause anyway, I prefer Immediate and Underlying Causes. Root Cause implies that there is one or one significant cause of the incident, which is rarely the case. A competent investigator will be aware of the complex interactions without resorting to RCA. There was a time when people were told to "stick to the facts." This is not case now either. Subjective/anecdotal comments are a legitimate means to express or understand the complex latent and active failures associated with many incidents.

So what is a root cause if it's not a single underlying cause? If you're saying that there may be multiple root causes, but they aren't underlying causes (or the underlying causes are not root causes, but there are multiple root causes) that sounds to me more like an argument about semantics than about safety - if there's multiple similarly-significant root causes then they are underlying causes, to my mind, and there's littel benefit classifying one as a root cause if preventing any could have prevented the incident. Please clearly and unambiguously define what makes a root cause that means it isn't an underlying clause (and/or vice versa, of course, if that's what you mean). In my view, accidents are rarely as simple as any of these tidy classifications suggest. Grouping things into a group of underlying causes at least acknowledges that. If you turn to the venerable swiss cheese model, deciding which one slice was the root cause when any one of the slices could have prevented the accident is (at best) a waste of effort.

Immediate Cause - The trigger(s) for the event without which that particular incident couldn't have happened. This may be a single event or a small number of events that started the incident Underlying Cause - The failures that contributed to the event happening and explain the occurence of the Immediate Causes. Root Cause - The most basic cause (or causes) that can reasonably be identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood of) the problem’s recurrence.

Agree Ray, Our group moved away from the term root cause analysis a while back in favour of Causal Factors Analysis taking into account a number of areas. In line with various techniques and areas of study which has showed that there is rarely a single root cause that the event can be apportioned to. This taking into account the linkages between management/ system / organisational failures/ behaviour and the good old active and latent conditions which "cross paths" with a dash of good (or bad) timing.