Chapter 2 2. Literature Review Root causes analysis is simply a tool designed to help incident investigators describe what happened during a particular incident, to determine how it happened and to understand why it happened. The definition of a root cause varies between authors and root causes methodologies, with different ‘levels’ of causation being adopted by different systems. Figure 1 illustrates the different levels of cause that can be ascribed to an incident. The root causes lie at level 1 which inevitably influence the effectiveness of all the risk control systems and workplace precautions that exist at levels 2 and 3. The most useful definition identified to date is the definition used by Paradies and Busch (1988), that is: The most basic cause that can be reasonably identified And that management has control to fix This definition will be used for this review. It contains three key elements: Basic Cause: Specific reasons as to why an incident occurred that enable recommendations to be made which will prevent recurrence of the events leading up to the incident. Reasonably Identified: Incident investigation must be completed in a reasonable time frame. Root causes analysis, to be effective, must help investigators to get the most out of the time allotted for investigation. Control to Fix: General cause classifications such as ‘operator error’ should be avoided. Such causes are not specific enough to allow those in charge to rectify the situation.