RCA That Sticks: Find Systemic Causes and Prevent Repeat Failures

Join us in person for a hands-on session where you'll learn how to dig deep, uncover the root causes of issues, and stop those annoying repeat failures cold. Perfect for anyone tired of quick fixes that don’t last. Let’s get to the bottom of problems together and make your solutions stick for good!

Info: We’ll start with introductions, course goals, and what “good RCA” looks like in high-risk operations. Then we’ll place RCA in the broader problem-solving toolbox and move into problem definition—framing issues in business and operational terms. You’ll practice this immediately in Workshop 1 using case material (SpaceX / Titanic / Deepwater Horizon). From there we’ll build the core skill: cause mapping in a team setting, using a clear cause taxonomy that progresses from functional to physical to human to systemic causes. Workshop 2 uses 5-Why as a discipline to strengthen cause logic (not as a shortcut). We’ll close Day 1 by focusing on evidence: what to collect, how to use it, and how to avoid “storytelling” in the cause map—ending with Workshop 3 (evidence planning for field incidents) and a wrap-up of key takeaways.

Info: Day 2 opens with a quick recap and the most common failure modes in RCA (stopping at human error, weak evidence, or weak actions). We’ll then work through how to verify causes and apply basic data analysis to confirm or eliminate hypotheses. In Workshop 4, teams run a full RCA on Deepwater Horizon, strengthening multi-path cause maps and validation logic. Next we shift from causes to solutions: how to develop corrective actions that actually prevent recurrence by prioritizing solutions using the hierarchy of controls. Workshop 5 is structured solution brainstorming, followed by Workshop 6 where participants apply the full end-to-end process to participant-sourced or provided cases. We’ll finish with practical guidance on sustaining RCA practices for business impact and keeping investigations focused on system improvement.

Know what’s Happening Next — before everyone else does.

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Host or Publisher Luis Suarez @ TechGopher