An integrated approach to the analysis of incident causes

Root cause analysis (RCA) is a well-established method for the determination of incident causes. However, the application of the method, especially for accidents in complex socio-technical systems, encounters limitations. It cannot identify some types of causes. This article finds ways to deal with the limitations, and integrates them into the RCA procedure. It results in the proposal of the Integrated Procedure of Incident Cause Analysis (IPICA). The integrated approach is based on the integration of assumptions about the structure of safety management in the investigated process into a comprehensive picture. It offers an integrated view of various types of causes. To a necessary extent, it integrates a non-linear incident model into the RCA procedure. The example – an analysis of the Walkerton tragedy from 2000 – illustrates the application of the integrated approach. IPICA is shown to be more universal than RCA, just as effective, and not excessively complicated.