What RCA is (and what it is not)
Good RCA is not a template exercise. It is a structured way to understand why the outcome made sense to people at the time — and what conditions shaped their decisions.
We focus on system-level contributors: interfaces, handovers, incentives, supervision, planning, tools, competence, and how work is actually done.
Why blame-free RCA matters
- People share information openly (you get the real story)
- You identify systemic causes, not convenient scapegoats
- Actions become practical and implementable
- Repeat events reduce because learning is real
Our RCA process
- Clarify the learning goal and scope
- Interviews and field understanding (work-as-done)
- Document review (procedures, training, maintenance, prior events)
- Analysis of contributing factors and decision points
- Practical actions with owners, deadlines, and verification
- Leadership briefing and communication support (optional)
What you get (deliverables)
- Clear RCA report (no jargon)
- Timeline and key decision points
- Contributing factors and root causes
- Prioritised actions (quick wins + structural improvements)
- Follow-up support to ensure actions close
Where this fits
RCA is often part of a broader workplace accident investigation. It also supports proactive learning from near-misses.
Getting started
Email [email protected] with a short description of the event (or near-miss), location, and urgency.