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the problem, but reaches further to consider all factors that influence the problem –including the people, processes, environment, equipment and external factors. 8Rootcause analysis, regardless of methodology, involves some degree of each of thefollowing:• Investigation to identify the problem• Determining the cause of the problem• Identifying and implementing solutions• Monitoring and sustaining results 9II.Step One: Identify the Problem (Investigate)The initial step in the process involves conducting an investigation to identify theproblem at hand. This actually includes several underlying issues to be addressed.Chief among them is the determination of what incidents or events to make subject to aroot cause analysis. It is possible that the decision may be forced upon you – by law,regulators, customers, or the sheer magnitude of the issue requiring investigation. Inother situations, the choice is not as clear as one might think.A business mustevaluate and decide what factors are important to it in determining whether to takeaction. Is moderate injury enough? Are multiple events and/or claims the triggering8 Lee N. Vanden Heuvel, et al., ROOT CAUSE ANALYSIS HANDBOOK: A GUIDE TO EFFICIENT INCIDENTINVESTIGATION 10 (3d ed. 2008).9 Okes, supra at 5.5