After a mishap, which level do investigators typically first address during root cause analysis?

In root cause analysis following a mishap, investigators typically first address the operator level. This approach is focused on understanding the actions, decisions, and behaviors of individuals directly involved in the incident. By starting at this level, investigators can gather insights into the immediate circumstances of the mishap, including operator performance, adherence to procedures, and the overall environment in which the operator was functioning at the time of the incident.

This level of analysis is critical because mishaps often occur due to human factors, such as miscommunication, oversight, or errors in judgment. Investigating at the operator level allows for a detailed examination of these aspects and can lead to identifying specific actions or shortcomings that contributed to the mishap.

Further analysis can then expand to higher levels, such as the system level or organizational level, but addressing the operator first helps pinpoint direct causal factors that are often the most easily identifiable and actionable. This framework is essential for developing effective corrective measures and improving overall safety protocols within the organization.