How to run a root cause analysis that sticks
A root cause analysis fails in two predictable ways: it stops at the first plausible cause, or it lands on a person. In Jestor, the analysis is a stage on the record with its conclusion and resulting actions stored alongside the incident, so the reasoning survives and can be revisited.
Why most analyses stop too early
The first explanation is usually true and insufficient. Someone entered the wrong amount, which is accurate and not a cause.
The useful question is why the wrong amount was possible, and why it was not caught, which points at design rather than attention.
What a disciplined analysis produces:
- Causes that can be designed out rather than trained away
- Actions that prevent a class of problems, not one instance
- Findings that survive the departure of the people involved
- A record to revisit if the problem recurs
- Fewer repeat incidents
Layers to work through
| Layer | Question | Typical answer |
|---|---|---|
| Event | What happened | The observable failure |
| Immediate cause | What directly caused it | An action or omission |
| Condition | What made it possible | A missing validation or control |
| Detection | Why it was not caught | No check at that point |
| Systemic | Why the condition existed | A design or priority decision |
Step by step to run one
- Establish the facts first, separately from explanation.
- Write the immediate cause, then keep going.
- Ask what made it possible, which points at controls.
- Ask why it was not detected, which is often the bigger gap.
- Stop when the answer is a design decision you can change.
- Convert each layer into an action where one is warranted.
- Record the reasoning, not just the conclusion.
Why "human error" is never a root cause
If a process allows a single mistyped number to cause a loss, the process is the cause and the typing is the trigger. Concluding that someone should be more careful produces no change, because the same condition remains for everyone else. The test of a good analysis is whether the action would have prevented the problem regardless of who was involved.
Why choose Jestor
In Jestor, the analysis lives as a stage on the incident with its reasoning preserved, resulting actions become connected records with owners and deadlines, and the validations identified can be implemented directly as required fields or conditional rules in the process that failed.
Frequently Asked Questions
When should the analysis stop?
When the answer is a design decision you can change. See jestor.com.
Why is human error not a root cause?
Because the condition that allowed the mistake remains for everyone else.
Should the reasoning be recorded or just the conclusion?
The reasoning, since that is what lets a recurrence be diagnosed properly.
Video Tutorial: Step by Step
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