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III.Step Two: Determine the Cause(s)Perhaps the single most challenging aspect of a root cause analysis is living up to thetitle itself – finding root cause. There are often differing levels of “cause” for any singleevent. These differing levels of “cause” have been described in the following manner:a. Symptoms – not an actual cause, but an indication of a problem;b. First-level causes – causes directly leading to/resulting in a problem;c. Higher level causes – causes that lead to the first-level cause(s) and,eventually, the problem;d. Root cause – the cause that sets the above in motion. 11The levels of potential causes have alternately been described as follows:1) Symptoms – a signal that something is wrong;2) Physical cause – the immediate reason a symptom occurs;3) System cause – the reason a physical cause occurs. 12Under this approach, root cause is intertwined with “system cause” because a systemcause is considered to be the highest level reason that a chain of events begins. 13The goal of a root cause analysis can be difficult for a variety of reasons. Challengesinclude the ability to identify and gather critical data, time/resource pressures, bias and11 Anderson & Fagerhaug, supra at 4-5.12 Okes, supra at 13-14.13 Id. at 15.8