Originally Posted by
positiverate20
The root cause was that the driver was not qualified to undertake that journey.
A small but crucial point (l used to teach this stuff). A root cause analysis should always, where possible, have at each step
someone doing something and then ask
why. Otherwise we’ll stop too soon, or go off down the wrong track. So the statement should be
”a contributing factor was that
the driver undertook that journey when he was not qualified to do so”
Then we get an obvious “WHY?” to ask. Maybe he thought he could get away with it. Why? Maybe he was under pressure. WHY? Maybe he was doing a favour for someone. WHY? Maybe he was unaware of the risks. WHY?
... and so on. You see my point. It opens up the causal tree, rather than closing it down. We then get more questions. Usually it will start with the kit and its operations and slowly focus in on organizational and human factors.