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Trigger the RCA process, that is, officially launch the RCA project. b. Mandate and organize the RCA team; the former can seem somewhat bureaucratic, but the mandate is important in providing the RCA team with the necessary authority to collect evidence and data, propose solutions, and so on. Organizing also involves resourcing, that is, appointing team members and ensuring their availability. c. Plan the RCA project by defining the tasks to be performed, by whom, by when, and milestones. d. Describe the event in detail; this is probably the most demanding of these substeps.

Precise description of event Both describe situations where consultations take too long because a urine sample must be taken during the consultation. Depending on how the problem is described, the remedy takes on quite a different nature. Step 1: Define the Event 29 Eliminate Bias A precise description of the event depends on elimination of bias and emotion, and avoiding thinking about causes at this stage. Both the RCA team and stakeholders will harbor emotions and views about what happened, especially those affected by the event.

However, the analysis is compromised when finding the “root” is separated from the other key steps in the process, with the team finding itself at odds, working on a solution to a situation not adequately defined. • The analysis often ends with the identification of the root cause, with less attention paid to the generation of solutions. • Few analysis teams test the solution by measuring its outcomes and making adjustments if necessary. • Few teams spread the products of their good works, allowing others to transfer and apply the knowledge to their own similar environments.

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Analysis of a Reflooding Experiment (csni79-55)


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