When something goes wrong at work, whether it’s a safety breach, a system failure or an operational setback, the instinct is often to fix the visible issue and move on.

But what if the problem isn’t what it seems?

  • What if that quick fix fails again, only this time with more serious consequences?
  • What if the same issue resurfaces in another part of the business, undetected until it causes major disruption?
  • What if a missed root cause leads to injury or worse?
  • What if regulators begin asking questions that your investigation cannot fully answer?

Treating symptoms rather than causes creates blind spots. It allows risk to build quietly until it escalates. And when it does, the impact, whether operational, financial, reputational or human, is often far greater than it needed to be.

At this point, identifying the true root cause is no longer optional. It is critical.

Why Root Cause Analysis is essential

Root Cause Analysis (RCA) gives organisations a structured, repeatable way to understand what really happened and why. It shifts the focus from surface-level fixes to the underlying factors that drive incidents in the first place.

Focusing only on symptoms leaves deeper issues unresolved, keeping organisations trapped in what we call the “cycle of repeat failures.” It’s a frustrating and costly position, but it can be broken with the right approach.

A strong RCA approach cuts through assumptions, brings clarity to complex issues, and helps investigators get to the ‘real why’, so actions taken actually prevent recurrence.

COMET’s three core truths about root causes

  • Root causes don’t occur inisolation.
  • Root Causes don’t have a hierarchyof seriousness.
  • They don’t change based on the failure type; the same causes often appear in completely different scenarios.

These truths help organisations avoid common pitfalls, such as only tackling the part of the problem that’s easiest to see. By doing so, they reduce the risk of similar incidents reappearing later in a different form.

The symptom is NOT the cause

Take a simple example. Imagine someone trips over a cable in a hallway. The instinct might be to say the cable caused the fall. But that’s the symptom, not the root cause. The real questions are: why was the cable there in the first place? Was it part of a wider issue with storage? Poor planning? A missing procedure? Was someone rushing because of unrealistic deadlines?

True root cause analysis digs below the surface. It asks the difficult questions. And it uses structured methods, not guesswork, to arrive at answers that are consistent, fair and practical.

Why structure matters in RCA

Effective RCA depends on a repeatable process. Without a structured framework, it's easy to miss important factors or let bias influence findings. That’s why COMET’s methodology is built on two core tools: a coded taxonomy and what we call root maps to guide the investigator to the root causes and systemic trends.

What is a coded taxonomy?

COMET provides structure through a coded taxonomy that defines root causes, grouped into five parent categories: Communication, Operating Environment, Management, Equipment and Training. This taxonomy helps investigators avoid subjective judgment and supports consistency, especially in complex cases involving multiple contributing factors. By coding each cause, organisations can group incidents, identify systemic issues, and analyse trends across teams, projects, or entire business units.

The result is insight that’s not only accurate but also actionable.

Rather than relying on personal judgment or opinion, investigators use the COMET process to guide their thinking. It supports objectivity and consistency, especially in complex cases where multiple causes may overlap. Each root cause is coded for clarity, helping teams group incidents, analyse trends, and focus on recurring issues across departments, projects, or locations. This enables an organisation to learn not simply from one incident at a time, but from the holy grail of multi-incident cumulative learning. 

What are Root Maps?

COMET’s Root Maps provide a disciplined framework for thinking beyond the obvious. In the aftermath of an incident, it’s all too easy to focus on what’s immediately visible. Root Maps counter that tendency by guiding investigators through a structured sequence of evidence-based questions designed to expose deeper, less obvious contributing factors.

Each step on the map prompts critical thinking, helping users challenge assumptions and identify contributing factors that might otherwise go unnoticed. By exploring these interconnected paths, investigators reach findings that are consistent, unbiased, and rooted in data, not guesswork.

Why cumulative learning matters

One investigation can reveal immediate lessons, but real safety improvement comes from spotting patterns across multiple incidents over time. Organisations that connect findings from different sites, projects or departments gain a clearer understanding of the systemic issues that single investigations might miss. Without access to structured, company-wide investigation data, valuable trends are lost, risks remain hidden, and opportunities to prevent serious incidents are missed. Isolated investigations might fix local problems, but only cumulative learning helps build a safer, more resilient operation across the whole business.

Want to know how other organisations are stopping repeat failures?

We reviewed investigations across six global organisations using COMET’s methodology and identified the ten most frequently recurring root causes. These are paired with real-world preventive actions used by top-performing teams to reduce risk and strengthen operations.

If you're looking to improve safety outcomes, reduce incident frequency and create a more resilient organisation, this guide will be a valuable resource.

Download the guide: The Top 10 Root Causes found in COMET Investigations – and how to prevent them