It’s amazing how quickly failure data (evidence) can disappear after a ‘failure’ has occurred. Following such an unexpected incident, there is sometimes a lot of confusion. Most sporadic/acute incidents occur on off-shifts or on weekends which can add to the confusion. Statistically, for a continuous manufacturing operation, there are more night and weekend hours than normal single-shift operating hours. Nobody is sure what to do or who to call to preserve failure data. All everyone knows is, “We better get this process or piece of equipment back on line.” This ‘production first’ paradigm drives the scene.

Over the years Root Cause Analysis (RCA) has become a word that is now associated with many types of problems. At one time the National Transportation & Safety Board (NTSB) was unique in its use referencing the conclusion of an airline crash investigation as the root cause analysis of the mishap. Today the word Root Cause is heard on the news more often and associated with all kinds of events. Events can range from the Root Cause of 9/11 to the Root Cause of a factory explosion.