Applying Lessons Learned from Accidents

Root Cause Analysis - Continued

Photograph of a culturally diverse group of men in business suits seated at a table. One of the men is writing.

At the heart of root cause analysis is the knowledge that things do not just happen. Events are caused to happen and by understanding the causes, we can decide which ones are within our control and manipulate them to meet our goals and objectives.

There is a strong link between root causes, decision-making, and lessons learned, especially in:

Establishment and communication of a regulation or policy.
Application of a regulation or policy.
Establishment and communication of monitoring and oversight.
Enforcement of that regulation or policy, based on monitoring and oversight.

With accident reports, many investigators are not given defined guidance or do not use a consistent and reproducible methodology. This could be due to widely differing, personalized accident investigation products and accident data. Understanding these factors and differences can help engineers conclude what the root causes really are and what lessons should be learned.

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