Getting to the Root – It’s Almost Never One

In audits, investigations, or improvement reviews, we’re often asked:

❓ “What was the root cause?”

But here’s the truth:

🔍 There’s almost never just one root cause.

Focusing only on a single explanation can lead us to overlook contributing factors, missed barriers, or deeper systemic issues.

It's almost never one!

🔧 How Do You Determine Root Cause?

Root Cause Analysis (RCA) isn’t about assigning blame, it’s about using structured tools to dig deeper and challenge assumptions.

Here are some practical methods we recommend:

✅ 5 Whys

Ask “why?” repeatedly until you get to the heart of the issue.

• Best for: Straightforward or linear problems

• Why it works: It’s simple, accessible, and surprisingly powerful when facilitated well.

🎥 Bonus: Ever seen the 5 Whys in action?This fun 3-minute video shows a persistent child asking "why?" again and again:👉 https://www.youtube.com/watch?v=FJ0eWm5PxkU

(Parents, you’ll relate. 😉)

✅ Fishbone Diagram (Ishikawa)

Maps out categories of potential causes — such as people, process, equipment, environment.

• Best for: Group analysis or multifactor issues

• Why it works: Helps avoid tunnel vision by exploring multiple angles in parallel.

✅ Bowtie Analysis

Visualizes causes on the left and consequences on the right — with barriers in between.

• Best for: Understanding how risks are managed

• Why it works: Clarifies both prevention and mitigation paths.

✅ Barrier Analysis

Examines what defenses failed or were missing.

• Best for: Incidents and safety-critical reviews

• Why it works: Connects RCA to risk-based thinking.

What About Classification?

Some organizations use fixed RCA categories like:

• Organizational Culture

• Human Error

• Inadequate Procedures

• Resource Shortages

• Competence Gaps

These can be helpful — but they don’t replace thoughtful, structured analysis.

💡 Tip: Let data guide your investigation, not stop it.

Key Takeaways

✅ There is almost never just one cause

✅ Use structured tools to guide, not guess

✅ Always look for missed barriers and contributing factors

How We Help

At Glacier Aviation Consulting, we support methods that bring clarity — and help teams make practical, safety-driven improvements.

Simple – Practical – Effective