Tutorial on learning lessons and root cause analysis

Learning lessons from events that have happened is an important contributor to good risk management and general decision making. Root cause analysis is a key tool for learning lessons. Organisations use root cause analysis to provide a consistent and systematic approach to learning lessons from both successes and failures, and to apply them to improve future performance.

This tutorial describes methods that can be adopted for learning lessons and generating improvements. It describes two root cause analysis approaches: fishbone analysis, and cause and effect analysis.

Organisations can benefit from undertaking ‘post-event’, ‘post-change’ or ‘post-decision’ analyses for all significant initiatives that they implement. They can also learn from unexpected events that might arise from a planned activity, or from external sources. The methods described here are generally applicable to all processes, initiatives and activities. They can be applied after an accident or adverse event but there is often much to be learned by examining the consequences of planned work and the effects of unexpected beneficial outcomes.

Read the full tutorial here.