Root Cause Analysis

White Paper by Steven D. Rivas, PMI-RMP®

E x e c u t i ve S u m m a r y

Accuracy is paramount within the mission critical operations of public safety

communication centers.

This white paper examines case studies where human error and technology were
predominant factors resulting in a reduction of readiness for responders, loss of
human life and/or property, and concludes with a summary of recommendations
to mitigate risks in the dispatch environment.

Methodology

Root Cause Analysis case studies initiated in response to an inquiry requiring

detailed evaluation of cascade events that often lead to unforeseen and harmful
results were reviewed for this white paper.

Table of Contents

1. Introduction
2. Humans and Technology
3. Cascading Events
4. Case Study: With the Click of A Mouse – Error.
5. Reduction of Readiness
6. Risk to Life and Property
7. Recommendations