October 19, 2018 | Mark Paradies

Can You Perform a Root Cause Analysis on a Natural Disaster?

A heavy rain in the mountains near Santa Barbara County produced a debris flow that killed 23 people including 19 people who were in a “voluntary” evacuation zone. Below is a map of the fatalities and the evacuation and voluntary evacuation zones.

David Boyd, of the citizen group “Montecito Emergency Response and Recovery Action Group ,” asked county commissioners to perform a root cause analysis of the loss of life to better assess the corrective actions needed.

County Officer of Emergency Management Director Rob Lewin said that he was unaware of “any such report for civilians caught in natural disasters.”

Could a root cause analysis be performed to find and fix the root causes of these types of deaths? Of course it could.

It would start by collecting the facts and building a detailed SnapCharT® of what happened.

Next, the investigators would identify the failed Safeguards (Causal Factors) that contributed to the fatalities.

Finally, each of the Causal Factors would be analyzed using the Root Cause Tree® to find the root causes.

One could look for generic causes to see if the problems exist outside Santa Barbara County.

Finally, the investigators and the county management would develop corrective actions to improve emergency response to future natural disasters.

There doesn’t have to be blame. There should be learning and improvement.

To find out more about using the TapRooT® System to perform a root cause analysis, see:


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