Typical Errors Before the Start of Root Cause Analysis
Bill Wilson, Analyst, Canada, SIG Leader
Samir's answers are good, high-level examples of what can happen DURING an investigation (sounds like he and I could have been on the same investigation teams). I'd like to address a few errors that occur BEFORE the RCA effort even starts.
1. Evidence is disturbed, cleaned up, or discarded: to the extent possible, evidence should be quarantined and left as-is until the RCA team has had a chance to go over it thoroughly.
2. The RCA effort is started late: sometimes, it isn't obvious that a RCA is required. Other times, it is blindingly obvious that RCA is required but nobody wants to admit it. Either way, the longer you wait, the more difficult evidence-gathering and investigation will be.
3. The RCA effort is not granted priority from the beginning: if the RCA team is constantly having to fight for office space, supplies, time away from regular duties, witness time for interviews, specialized forensic/failure data, they're going to have trouble doing a good job.