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Root Cause Analysis: Five Whys and Fishbone Method
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Root Cause Analysis: Five Whys and Fishbone Method

The proximate cause of a failure is almost never the root cause. A bearing seizes because lubrication failed — but lubrication failed because a seal was worn — and the seal was worn because the maintenance interval was set for a different operating environment. Stopping at the bearing and replacing it solves nothing. Root cause analysis is the discipline of following the causal chain back far enough that the corrective action prevents recurrence, not just repairs the immediate damage.

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Failure Documentation and Lessons Learned Systems
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Failure Documentation and Lessons Learned Systems

Every failure analysis investigation produces knowledge that cost the organisation time, money, and sometimes safety incidents to acquire. That knowledge is worth nothing if it lives in one engineer's head, in an email thread, or in a report filed in a cabinet that nobody opens. The difference between an organisation that learns from failures and one that repeats them is not the quality of its investigation methods — it is whether the results of those investigations are documented, accessible, and actively used in future design decisions.

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