Root Cause Analysis Master Class

 In Articles, Root Cause Analysis, Structured Problem Solving

This recently came to my attention and I’m sharing it because I know that some of you appreciate a good investigation and root cause analysis as much as I do.

On April 30, 2015, a fire erupted on board an Air Force RC135 jet. Fortunately, the jet had taken off only a few minutes before and the pilot was able to land the plane in time for the crew to escape without any fatal injuries. The property damage to the jet is estimated at $65 million.


Lieutenant Colonel William M. Evans, Jr. was assigned the investigation on June 8, 2015, and began his investigation on June 12. Evans completed the investigation, root cause analysis, and full report by June 30, 2015.

That is only 19 days counting weekends. Judging from the thoroughness and vigor of the report, Col. Evans must have used just about every one of the 456 hours he had available to him.

Please check out the report, which speaks for itself and is a model of how to conduct and record an incident investigation.

Kudos to Col. Evans.

(For what it is worth, Col. Evans found that the root cause of the fire was a failure to properly tighten metal oxygen tube fitting).

Also published on LinkedIn.