Root Cause Analysis MANCP Network November 2012

Multiple causes Ambition –how deep Formulate a common ambition, looking for multiple probable causes/contributors Responsibility what level/who Trends at central/regional level – Focus on system not individual – Significant trends or failure to make progress towards objectives

Root cause may be at FBO or control system level Assessment of interventions to date

What to monitor At what level Scope of inspections Checklists Enforcement How to select data to aggregate For what problem do you want to find the cause Intervention strategies

Questions-Answers USE – Improve controls – Intervention at level of cause not effect Where done – In places, not consistently Why done – See use Why not done – Not convinced of benefit – Resources – Not willing to highlight issues