The Latent Cause Analysis

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ROOTS Essential Elements

ROOTS Essential Elements

 

These are the MINIMUM things that a Principal Investigator ought to do when requested to lead a Latent or Root Cause Analysis. Please do not call your efforts a Maxi-LCA if you omit any of the following: 

 

1.  Respond: Gather the "5 Items."

2.  Respond: Acquire 3 evidence gatherers, one for each of the 3 Ps.

3.  Respond: List the evidence to gather with the help of the client’s people, one list for each of the 3 Ps.

4.  Respond: Gather and summarize the evidence. Do your best to keep the 3 Ps separate (do not let the 3 Ps talk to one another).

5.  Respond: After combining the 3 forms of evidence with the evidence gatherers, try to identify the Physical, Human, and Latent Causes of the incident with the evidence gatherers. If you cannot define the Physical, Human, and Latent Causes, you do not have enough evidence. Determine additional evidence needs, gather, and summarize until you can define Physical, Human, and Latent Causes. These are to be considered PRELIMINARY causes, and are NOT to be shared with the stakeholders.

6.  Organize: Identify the stakeholders.

7.  Order: Present the summarized evidence to the stakeholders.

8.  Order: Have the stakeholders define:

Physical Causes (complete sentences, paragraph style, past tense and specific)

Human Causes (who did what wrong, bulleted style, past tense and specific)

Latent Causes (bullet-style, present tense and generic, using the S-F-O model prior to generating the answers)

What is it about the way we are the contributed to this event?

What is it about the way I am that contributed to this event?

Action Items that are SMART (specific, measurable, actionable, reasonable, and time-bound).

9.  Translate: If requested, provide a written report that follows the Failsafe template.

10.  Translate: If requested, work with the stakeholders to create an effective Translation.

11.  Sustain: Be prepared to explain how you investigated the incident to the rest of the Mother-Source members.

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