Determine the key factors that contributed to the incident.
ROOT CAUSE FAILURE ANALYSIS
RCF A is a systematic approach to identify and eliminate the failures that prevent a business from achieving its goals (e.g. 100% uptime, zero injuries, meeting cost objectives, etc).
The RCFA process identifies the causes of failures (key factors) at the equipment, human, and systems levels and puts in place corrective measures to eliminate them resulting in improved, sustainable performance.
Circumstances that contributed to or may be reasonably believed to have contributed to the incident's occurrence even though a clear causal connection may not be found.
These circumstances include human, equipment and/or operating/managing systems that are found to be deficient or otherwise capable of being improved
