So What Really Happened?
"Incident Investigation and Root Cause Analysis"
Author: James Dolan
Published: October 1998
While M&O had performed root cause analyses for decades, in 1998 the concepts of root cause analysis started to become a more regular and formal process in ship operations offices and aboard ships.
In this paper Jim Dolan provides a root cause analysis primer. While the methods described are fully relevant today, it is interesting to note that terminology with regard to root cause investigation is still in flux.
To download the full paper click this link: Incident Investigation and Root Cause Analysis