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Root Cause Analysis:Looking for Black & White in a World of Gray 1When something unplanned happens, we all want answers. It’s human nature. Thelengths to which one will go to determine “why” is typically in direct proportion to theperceived seriousness (or frequency) of the event. For example, a guest falls whiledescending the stairway in your home. The guest professes to have “slipped” on a stepand assures you that they are not hurt, merely shaken. You take a quick look at thestairs and do not notice anything that appears significant at all. Given your guest’sexplanation, you make no further inquiry. In contrast, consider the level of inquiry whenthe injury is a broken bone, or when several people fall on the step. You now examinethe stairs in detail and you notice a slight “hump” in the stair in the area where the fallshave occurred. Digging further, you discover a loose board under the carpet that moveseach time guests step on it. In all likelihood, you repair the board and carpet and moveon. Some, however, may dig even further to find “why” the board came loose in the firstplace, determining who or what created the condition that led the board to loosen overtime.In this simple example is a microcosm of what is known as “root cause analysis” – theinvestigation, analysis and determination of the factors that lead to an event. While notevery business will use this terminology, each will, at some point, likely perform what inessence is a root cause analysis of a product, process or business practice. Even if theterminology is used, however, differing approaches or styles may be used to performthe investigation and analysis. Even more frustrating for those who seek accurate1 Article prepared by ALFA International attorneys J.K. Leonard (Naman Howell Smith & Lee, PLLC, SanAntonio, TX) and Peter Dubrawski (Haight, Brown & Bonesteel, LLP, Los Angeles, CA).2