# safety-RCA-analysis

> Systematic root cause analysis methodology for safety incidents using 5-Why, Fishbone, and Fault Tree Analysis techniques

- Skill: `construct-ai-primary/safety-rca-analysis` (Agent Skill)
- Install (CLI): `npx skillmds@latest add construct-ai-primary/safety-rca-analysis`
- Raw SKILL.md: https://api.skillmd.com/api/skills/construct-ai-primary/safety-rca-analysis/raw
- Safety review: pending (external: skill-scanner PASS, skillspector PASS)
- Works with: Claude Code, Claude.ai, OpenAI Codex
- Category: Coding & Dev Tools
- Author: Construct-AI-primary (https://skillmd.com/u/construct-ai-primary)
- Updated: 2026-09-21
- Page: https://skillmd.com/skills/construct-ai-primary/safety-rca-analysis

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# Root Cause Analysis (RCA)

## Overview
Systematic root cause analysis for safety incidents using structured methodologies including 5-Why, Fishbone/Ishikawa diagram, and Fault Tree Analysis. Primary agent: Incident Investigation Specialist.

## Triggers
- Safety incident requiring investigation
- Recurring similar incidents identified
- High-severity incident (LTI, fatality)
- Regulatory requirement for investigation

## Prerequisites
- Incident details and initial report available
- Evidence collected and witness statements recorded
- Investigation team assembled
- Applicable investigation methodology selected

## Steps

### Step 1: Incident Description
Document the incident clearly:
- **What happened** → Sequence of events
- **Where it happened** → Location and area
- **When it happened** → Date, time, shift
- **Who was involved** → Injured persons, witnesses
- **Why it matters** → Impact (injury severity, damage, environmental)

### Step 2: Data Collection
Gather all relevant evidence:
- Photographs of the scene
- Witness statements
- Documentation (permits, training records, procedures)
- Physical evidence
- Equipment and material records

### Step 3: Causal Factor Identification
Identify all factors that contributed:
- **Direct causes** → Immediate events leading to incident
- **Contributing factors** → Conditions that enabled the incident
- **Root causes** → Systemic failures that, if corrected, would prevent recurrence

### Step 4: RCA Methodology Application
Apply selected analysis method:

**5-Why Analysis:**
- Start with the problem statement
- Ask "why" iteratively until root cause is identified
- Validate each "why" with evidence
- Typically 5 levels deep, but adjust as needed

**Fishbone/Ishikawa Analysis:**
- Create main categories: People, Methods, Materials, Equipment, Environment, Management
- Brainstorm potential causes for each category
- Analyse relationships between causes
- Identify most likely root causes

**Fault Tree Analysis:**
- Define top event (the incident)
- Identify immediate causes with AND/OR gates
- Work downward to basic events
- Calculate probabilities if data available

### Step 5: Root Cause Validation
Verify identified root causes:
- **Evidence-based** → Supported by collected evidence
- **Controllable** → Organisation can implement corrective actions
- **System-level** → Addresses systemic failure, not just symptoms
- **Recurrence prevention** → Correcting this cause prevents similar incidents

### Step 6: Corrective Action Recommendations
Generate corrective actions for each root cause:
- **Immediate actions** → Address immediate danger
- **Corrective actions** → Fix the root cause
- **Preventive actions** → Prevent recurrence across similar activities

## Success Criteria
- Root cause analysis completed within investigation timeline
- Root causes are evidence-based and systemic
- Corrective actions address identified root causes
- Analysis methodology documented and defensible

## Common Pitfalls
1. **Blaming individual** → Stopping at "worker error" without exploring system causes
2. **Insufficient evidence** → Root causes not supported by adequate evidence
3. **Too many root causes** → Over-analysis leads to diffuse corrective actions
4. **Missing contributing factors** → Focusing only on direct causes, missing systemic issues

## Cross-References
- `safety-incident-tracking/SKILL.md` — Incident tracking source
- `safety-CAPA-management/SKILL.md` — Corrective action management