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e it occurred (including frequency), and its significance (e.g., actual and potential severity of the consequences). Because the best teams include people with diverse experiences, perspectives will be different. Disagreements about problem definitions and causes can waste valuable time. Solid RCA practices will help teams create problem definitions on which everyone agrees. Evaluate the impact that the problem had on business goals and uncover the potential consequences of recurrence. The what statement, referred to as the primary effect in an RCA, helps those involved define the hazard. RCA Step 2: Define a Causal Understanding & Analyze Cause/Effect Create a cause-and-effect chart. Understand why a problem happened and the evidence proving it. What are the causal relationships among all the interdependent sets of action and conditional causes? The causeand-effect chart will define the lower-level details of the hazards in the risk analysis, thus making it easier to find proactive solutions. The third phase of risk analysis is evaluation. Compare and judge the significance of risks. What are all the risk agents? What are all the conditions under which the risk agents could occur and cause an adverse outcome? To answer these questions, conduct a cause-andeffect analysis (with dynamic analysis). Analyze the major cause paths on the cause-and-effect chart, along with those from other problems, to identify common causes (e.g., similar causes that contributed to more than one organizational problem). Identify systemic causes - those individual causes or groups of causes that identify where the system itself (i.e., the way the organization conducts its business) contributed to a problem. Systemic causes can manifest at the organizational level and include areas such as policies, procedures and work practices, as well as at the workforce level, including work practices and culture and at the individual level, including work practices, behavior, decisions and belief systems. Doing so will highlight how the ways in which an organization is conducts business could pose risks to multiple business goals. Implementing solutions for systemic causes may seem expensive when compared with the significance of any individual problem. However, this logic is flawed. In calculating return on investment, the cost of controlling a systemic cause must be contrasted with the combined significance of all problems to which it contributed. Integrating RCA Into Risk Management The first risk management phase is option generation - identifying alternatives for managing risk. RCA Step 3: Identify Solutions Challenge each and every cause by generating solution ideas, knowing that each cause could play a role in future incidents. Do not focus on a few causes at the expense of others, because something less obvious yet important might be overlooked. Favor solutions that will eliminate causes most likely to contribute to a future problem, especially those with more severe potential consequences. The second risk management phase is option evaluation - appraising and comparing available options. RCA Step 3.1: Evaluate Solutions Evaluate the potential effectiveness of various solutions relative to the cost of the problem and the solution's probability for success. Focus more on identifying the risk of specific individual causes rather than generic categories of causes. Do the solutions that control conditional causes have a greater certainty of controlling risk