🔍 Root Cause Analysis (RCA)
Practical Implementation Steps + Free Report Template
After any workplace incident occurs, the first question usually asked is:
Who is at fault?
But the correct question is: Why did the incident happen?
This is where Root Cause Analysis (RCA) plays a vital role. It is one of the most important tools in occupational health and safety, aimed at preventing incident recurrence rather than merely addressing their consequences.
🧠 What Is Root Cause Analysis (RCA)?
Root Cause Analysis is a systematic approach designed to:
Identify the true causes of an incident
Understand both direct and indirect contributing factors
Establish actions that prevent the incident from recurring
📌 RCA does not look for someone to blame—it looks for the root cause.
🎯 Why Is RCA Essential in the Workplace?
Implementing Root Cause Analysis helps to:
Prevent the recurrence of incidents
Improve the overall safety management system
Identify weaknesses in procedures
Promote a culture of learning rather than punishment
Comply with local and international legal and regulatory requirements such as ISO and OSHA
⚠️ Direct Cause vs. Root Cause
| Type | Definition | Example |
|---|---|---|
| Direct Cause | What directly led to the incident | Worker slipped |
| Root Cause | The real underlying reason behind the event | Inappropriate flooring + weak equipment maintenance system or lack of supervision |
📌 Treating only the direct cause means waiting for the next incident.
🛠️ Root Cause Analysis Steps (Step by Step)
1️⃣ Secure the Incident Scene
Prevent another incident from occurring
Protect evidence
Ensure everyone’s safety
2️⃣ Collect Information and Data
Witness statements
Photos and videos
Training records
Work procedures
Maintenance logs
📌 Every small piece of information may be the key to the solution.
3️⃣ Establish the Sequence of Events
What happened?
When did it happen?
How did the incident develop?
This helps in understanding the full picture.
4️⃣ Identify Direct Causes
Human errors
Equipment failures
Environmental conditions
📌 This is not the end—it is the beginning.
5️⃣ Use Root Cause Analysis Tools
Common tools include:
🔹 5 Whys Technique
Asking “Why?” repeatedly to reach the true cause.🔹 Fishbone Diagram (Ishikawa Diagram)
Analyzing causes under categories such as:People
Equipment
Environment
Procedures
Management
6️⃣ Identify the True Root Cause
A cause that can be controlled
A cause that, if addressed, will prevent recurrence
📌 Not every direct cause is a root cause.
7️⃣ Define Corrective and Preventive Actions
Technical controls
Administrative actions
Training
Design or work-method modifications
📌 A good action prevents incidents—it does not just make the report look good.
8️⃣ Implement Actions and Follow Up
Assign responsible persons
Set deadlines
Monitor effectiveness
📄 Root Cause Analysis Report Template
An RCA report typically includes:
Incident details
Incident description
Direct causes
Root cause(s)
Corrective and preventive actions
Responsibilities
Follow-up and verification
🚫 Common Mistakes in Incident Analysis
Searching for someone to blame
Closing the investigation too quickly
Ignoring management and organizational factors
Failing to implement corrective actions
Not sharing lessons learned