Root Cause Investigation Report
Root Cause Investigation Report
Prepared by: [Your Name]
Date: January 3, 2051
I. Executive Summary
This Root Cause Investigation Report investigates the incident that occurred on January 1, 2051, at [Your Company Name]. The objective is to identify the root cause and propose corrective actions to prevent future occurrences.
II. Incident Overview
1. Incident Description
On the morning of January 1, 2051, a significant system outage occurred, affecting the entire production line. The outage lasted for 4 hours, resulting in substantial downtime and financial loss.
2. Impact and Consequences
The outage disrupted operations, resulting in a production halt. The estimated financial impact is $500,000, including lost revenue and overtime labor costs.
III. Investigation Team
1. Team Members
|
Name |
Role |
Contact |
|---|---|---|
|
John Doe |
Lead Investigator |
john.doe@root.com |
|
Alice Smith |
System Analyst |
alice.smith@root.com |
|
Michael Johnson |
Engineer |
michael.johnson@root.com |
2. Roles and Responsibilities
The investigation team is tasked with data collection, root cause analysis, and developing corrective actions.
IV. Root Cause Analysis
1. Methodology
The team employed the 5 Whys technique and Fishbone Diagram to identify the root cause of the incident.
2. Findings
|
Cause |
Analysis |
|---|---|
|
Power Surge |
A power surge disrupted the main server, leading to the outage. |
|
Inadequate Surge Protection |
The existing surge protection failed to mitigate the power surge. |
|
Outdated Equipment |
Surge protection equipment had not been updated in 10 years. |
3. Root Cause
The primary root cause identified was the failure of the inadequate and outdated surge protection system, which could not handle the unexpected power surge.
V. Corrective Actions
1. Short-term Actions
Immediate replacement of the surge protection system and inspection of all related equipment within the next 30 days.
2. Long-term Actions
Implement a maintenance schedule for regular inspection and replacement of critical equipment every 5 years.
|
Action |
Owner |
Due Date |
|---|---|---|
|
Replace Surge Protection System |
James Lee |
February 3, 2051 |
|
Schedule Regular Inspections |
Linda Green |
March 1, 2051 |
|
Update Maintenance Protocol |
David Brown |
April 15, 2051 |
VI. Conclusion
This investigation revealed critical gaps in our surge protection system and maintenance protocols. By implementing the recommended corrective actions, [Your Company Name] will strengthen its operational resilience and mitigate future risks.
VII. Recommendations
Conduct an annual review of all critical systems and ensure all equipment is up-to-date with current standards.
For further details or inquiries about this report, please contact [Your Name] at [Your Email].
