Root Cause Analysis for Transport Incidents: 5 Steps to Get There

Getting to the root cause involves five steps. The steps themselves are not always easy, but the overarching process is not too hard to grasp.

1. Describe the problem or event

Write down the problem or describe the event you need to prevent. You may have had an incident where many things happened, but you need to work through each one in an RCA one by one. Start from the beginning of the issue — the first problem that occurred. Write this down in some detail, no more than a paragraph.

2. Ask why the problem occurs

Ask yourself or, better, the team working through the RCA: "Why does the problem occur?" Look for past events or ask staff through an interview process whether they have seen or felt this has occurred before. You would be amazed at how often things happen but go unreported.

Gather qualitative and quantitative data — the event may have occurred due to a specific element such as time of day or being rushed. Really step into why or how this event occurred.

3. Record all answers on paper

Write down the answer or multiple answers. It is important to record all your findings. You may want to reconvene later or take a break, and there may be much conjecture if this is being fleshed out in a team environment — so you do not want to lose any important element.

You may even need the notes if the incident occurs again to run a further RCA. It is also important to be able to show that you have conducted an RCA at a later date or in a court case, so it is wise to document your meeting minutes.

4. Ask "why" until you reach the root cause

You now have your root cause or, hopefully, a bunch of root causes as to how or why an incident occurred. Establish the final root cause(s) by asking yourself or the team why each root cause is in fact the root cause of the incident.

The best way to do this is to ask "why" — you cannot ask why enough during a root cause analysis. Keep asking until you reach an end point in the thought process. "Why" means "What were the factors that directly resulted in the incident?" What was the effect of the factors involved?

You can classify the answers into two categories:

• Causal factors that relate to the incident in sequence
• Root causes that — when removed — interrupt the steps of the process chain

5. Confirm the root cause and plan corrective actions

Continue to work through the RCA until you are satisfied you have reached the root cause of the issue. Identify all other harmful elements that have an equal or better claim to be the root cause. Often you will have multiple root causes, and it is important to work through these to ascertain the most optimum one.

Once this step is completed, you can move on to exploring corrective actions — to see if, with a high degree of certainty, they will prevent an incident like this from occurring again.

A great question to ask when evaluating a corrective action is: if this had been implemented before the incident, would it have significantly reduced the likelihood — or better, prevented the incident from occurring in the first instance?

There is no certainty that an RCA process will stop an event from occurring again. A check-in and visual inspection of the improved process should be conducted, but you will never fully know if what you have implemented is rock solid.

The only way to improve from this point is to complete a risk analysis of the new process with a fresh set of eyes — to determine if someone else foresees a risk in the process. No one is perfect, but together we can create a safer environment.

Documenting your RCA is not just good practice — it is evidence that your business takes safety seriously. Under the Heavy Vehicle National Law, every party in the Chain of Responsibility has a duty to manage transport risks. When an incident occurs, being able to show you investigated it thoroughly, found the root cause, and implemented corrective actions demonstrates that your safety system is working.

For operators maintaining NHVAS accreditation or building a Safety Management System, RCA records form part of the evidence trail. They show auditors and regulators that your business does not just react to incidents — it learns from them.

Key records to keep include:

• Meeting minutes from the RCA investigation
• The problem description and timeline of events
• All "why" answers and causal factors identified
• The confirmed root cause(s)
• Corrective actions implemented and their review dates

MAEZ helps Australian businesses turn Chain of Responsibility, HVNL, WHS, transport safety, and chartered risk obligations into practical training, advisory, audit, and implementation pathways.

If you need help running an RCA, building your SMS, or preparing for NHVAS accreditation, contact MAEZ for a practical review of the controls, evidence, training, and SMS gaps that matter most to your operation.

For businesses that need structured records, reminders, audits, maintenance logs, driver diary checks, inductions, corrective actions, and evidence reporting, Chain of Responsibility training and advisory work can be connected to your compliance systems.

MAEZ helps transport operators deal with the compliance risk they already know is there — find the gaps, fix the system, and prove the controls.