Click on any Blue words to get more information.
Coming together, meeting or joining. e.g. 2 leading to 1.
A line of logic which ends before a Root Cause is reached. This will be because it's a perfectly normal occurrence, or something you can do nothing about. e.g. train on normal journey or a weather issue. In French - cul de sac. We show this in the RCA diagram by closing off the Post-it with a solid underline.
Branching out. e.g. 1 leading to 2.
Something with the potential to cause harm or damage.
The conditions or events which were the direct cause of the incident.
A verb which is not present (hidden) in a sentence but which is taken to be present. e.g. 'Brakes off' implies that 'The brakes were off'.
An event which caused, or could have caused, damage or harm to people, the environment, equipment, process or reputation.
A short description of an incident which summarises 'What happened', 'The Consequences' and the 'Potential Consequence'.
Information which is provided in a more complex way than is necessary. Often generated by groups or professions to confer status and, some would say, mystique, to their activities.
A diagram where each step is linked with another in a sensible and sequential way.
This is a short statement of what might have happened, which adds gravity to the investigation.
Interaction with a hazard, e.g. A busy road is a 'hazard', crossing it is a 'risk'.
A logical system linking all the factors which contributed to an incident, and used to identify the actions required to remedy some or all of these factors.
The fundamental organisational and/or people factors that resulted in an incident.
An acronym used when making recommendations, and standing for Specific, Measurable, Accountable, Realistic, and Time scale.
The general conditions and failures which contributed to the incident.
An action word which should be used in all RCA Post-its to ensure that a question can be asked. e.g. 'Communication' on its own means very little. 'There were communication failures' means a lot more and we can ask 'Why were there communication failures?'