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Root Cause Analysis
Root Cause Analysis
Many layers of defense usually lie between hazards and accidents but there
are flaws in each layer which if aligned can allow the accident to occur.
Th e Pu n is h m e n t Myth
- if we punish people when
they m ake errors they will
m ake fewer of them
Five W h ys
Counter-measure: We need to find a supplier who can deliver ink at very short
notice.
Fis h bo n e D iagram
Re d u cin g th e like lih o o d o f e rro r
Re m e d ial actio n s s h o u ld