Case Study: What Caused This — A New Approach to Root Cause Analysis in Complex, Regulated Environments

The Scope: When Traditional Root Cause Analysis Reaches Its Limits

Across regulated sectors such as healthcare, aviation and energy, organisations rely on root cause analysis to understand what happened, why it happened and how future incidents can be prevented. But the environments these sectors operate in have changed. Systems are more complex, pressures are greater and events rarely follow a simple linear pattern.

Yet much of the industry still depends on traditional root cause analysis software that captures information in rigid formats, fails to reflect real-world nuance and often reduces rich human insight to a series of checkboxes. Important context becomes fragmented across systems. Human experiences sit in separate silos from operational data. And meaning is lost in the process.

Investigators and learning teams reported the same challenges again and again:

• incident narratives that could not be captured meaningfully

• insights trapped in disconnected tools

• slow and repetitive reporting cycles

• difficulty identifying deeper contributing factors

• limited visibility of patterns across cases

The result is an incomplete picture. Organisations meet compliance requirements, but the opportunity for meaningful learning and prevention remains out of reach.

The industries responsible for public safety needed something more thoughtful than traditional root cause analysis software. They needed a way to bring human stories, environmental factors and organisational context together, without oversimplifying what actually happened.

This is where What Caused This began.

The Solution: A Human-Centred Platform for Understanding Events

What Caused This is a collaborative platform designed to modernise how organisations capture, explore and learn from incidents. Rather than forcing users into predefined templates, it respects the complexity of real-world situations and places human insight at the centre.

The platform reimagines root cause analysis by focusing on context, narrative and shared understanding. It helps teams:

• capture nuanced descriptions of what happened

• explore contributing factors rather than jumping to a single root cause

• reveal connections across multiple events

• move from isolated case reviews to collective organisational learning

• transform rich experience into intelligence that can be acted upon

The approach is not to automate judgement, but to strengthen it. It supports human sensemaking, rather than replacing it. The ambition is to shift thinking from traditional root cause analysis to root cause intelligence, enabling organisations to see more of the system, not less.

More on the deliverable:
https://whatcausedthis.com/software

Our Approach: Co-designing with Experts in Regulated Sectors

To build the platform, we worked side by side with the team behind What Caused This using a co design approach. Instead of developing features in isolation, we embedded designers and domain specialists directly into their workflows.

We observed how investigators interpret events, how learning teams extract meaning and how organisations navigate compliance obligations. Through this work we gained a deep appreciation for the complexity of their reality, including:

• competing pressures

• environmental constraints

• informal practices

• communication gaps

• interactions between people, systems and processes

This allowed us to translate that complexity into a platform that supports human expertise, encourages deeper reflection and helps organisations see the wider system around each event.

Breaking the Limitations of Traditional Root Cause Analysis Software

Most tools treat each incident as a stand alone case. They record information, store it and move on. They rarely help teams connect events, identify themes or understand systemic influences.

What Caused This deliberately breaks that pattern.

It brings together:

• contextual narratives

• environmental and situational detail

• human perspectives

• contributing factors

• organisational insights

• visual exploration of events

The platform enables teams to see beyond the surface of a single case. Patterns become visible. Hidden connections emerge. Learning accelerates.

This approach aligns with emerging thinking in safety science, human factors and systems thinking, where the goal is not simply to assign blame or identify a single cause, but to understand the interaction of influences that shaped the event.

More on how the platform helps people see and understand across industries:
https://whatcausedthis.com/sectors

Looking Ahead: Root Cause Intelligence for a More Insightful Future

While the platform itself is grounded in human understanding, the future of organisational learning will increasingly involve artificial intelligence supporting the discovery of deeper insights.

The roadmap for What Caused This includes moving from traditional root cause analysis toward something more powerful: root cause intelligence, where human narrative, contextual data and AI enhanced insight work together to reveal patterns that might otherwise remain hidden.

This will not replace human judgement. It will strengthen it.
It will help organisations:

• recognise emerging risks sooner

• understand the complexity behind repeated events

• surface insights that improve safety, quality and performance

• learn at scale without losing context or nuance

This is the natural evolution of incident learning.
Not artificial intelligence making decisions on behalf of humans, but AI supporting a richer understanding of real situations, enabling more informed action.

A New Standard for Learning, Prevention and Organisational Insight

What Caused This represents a shift in how regulated industries approach incident understanding. It respects the honesty of human experience, the complexity of shared environments and the need for clear insight across entire organisations.

It brings narrative, context and intelligence together, helping teams move beyond compliance and towards genuine learning and prevention.

In a world where organisations face increasing pressure, complexity and public responsibility, the ability to understand what happened and why matters more than ever. What Caused This gives teams the tools to do that with clarity, depth and confidence.