Contributory factors

Contributory factors

Workers in a poultry factory

There are 3 distinct and significant contributory factors that may assist or inhibit the ability of the Root Cause Investigator to successfully complete the study – the organisation or establishment, the process or procedure involved and the people.

Organisation / Establishment

The culture of the organisation / establishment can have a huge impact on the success or otherwise of a Root Cause Analysis study. There are several questions that may need to be asked:

  • Are resources and support available from management to implement the recommendations and outcomes of the study?
  • Is there evidence of business pressures getting in the way now, in the past and in the future to prevent improvement?
  • Does a blame culture exist, where fault is found within the organisation / establishment?

The investigator should look for examples where management have stopped, vetoed or modified genuine and viable continual improvement measures without good, documented reasons.

Process / Procedure

In terms of the process or procedure that is being analysed, the study will need to establish:

  • Is the process that is under investigation valid and capable?
  • Is a reliable system in place for verifying or checking the process?
  • Does the process undergo regular reviews to assess its efficacy?

For each of these three questions, documentary evidence would be required to demonstrate that:

  • A validation study had been performed that includes and factors in the worst case scenario
  • The system is effectively monitored
  • That it is updated as necessary


Are the staff receptive to continual improvement?

Are there any potential issues with:

  • Established staff (reluctance to adopt new practices)
  • New or temporary workers (system unfamiliarity)

Do the staff demonstrate openness and trust?

Is training and refresher training up to date and adequate for the needs of the organisation?