Home / RCA Methods / The P3i Causation Model
THE MODEL WE USE
The P3i Causation Model
Every loss has a chain. We follow it to the end.
In every investigation, we trace five layers: the loss, the event, the immediate causes, the basic causes behind them, and the control gaps in the management system. The model is built on the loss causation model used by investigators internationally, and it works for safety, quality, business and information losses alike.
Since the 1990s
30
years investigating
250+
investigations closed, incl. HiPOs
15
countries served
20+
countries of lead seminars
100+
nationalities trained
Five layers
Loss
What was lost, or could have been
People, property, process, environment, quality, information, reputation, time.
Event
The contact or failure that caused the loss
Struck by, fall, contact with energy or substance, release, equipment failure, delivery failure, data loss, contract or licence breach.
Immediate causes
The acts and conditions just before the event
Substandard acts, such as bypassing a guard or failing to check; and substandard conditions, such as a defective tool, poor lighting or missing information.
Basic causes
Why those acts and conditions existed
Personal factors — capability, knowledge, skill, stress, motivation — and job factors: supervision, engineering, purchasing, maintenance, tools, standards, communication.
Control gaps
The management system weaknesses behind them
Missing, inadequate or unfollowed standards and programmes: planning, risk assessment, contractor control, change management, training, inspection, learning from incidents.
Follow one chain
Pick a case. See all five layers.
·
01 · Loss
Worker's hand injured; two days lost
02 · Event
Caught between a pallet and racking
03 · Immediate causes
Pallet moved while hand was placed to guide it; blind corner
04 · Basic causes
Night shift short-staffed; no banksman role defined; no training on guiding loads
05 · Control gaps
No staffing standard for night shifts; layout changed without review
Illustrative cases. The fix sits in layer five: change the control, and every future event of that kind becomes less likely.
Why the last layer matters
Stop at layer three, and you blame a person. Reach layer five, and you fix the system.
Most internal investigations stop at the immediate cause: the act or condition just before the event. The corrective action becomes retraining or a warning. By tracing basic causes and control gaps, our process specialists find the weakness that would have produced the next event too, and the one after that.
Want every investigation in your organisation to reach layer five? A first call costs nothing.
The P3i approach
How we investigate through all five layers. Fact-finding, not fault-finding.
Every P3i investigation is led by a senior investigator and supported by internationally qualified process specialists. You will not receive a list of people to blame, or a long list of generic actions. You will receive the facts, the proven causes, and a short plan that closes the gaps, in this case and across your system.
Independent
No products, repairs or contracts to sell you afterwards.
Senior-led
Thirty years of investigation, from the first call to the final briefing.
Beyond the event
Process specialists find the other cracks before they fail.
Ready to present
Written for boards, buyers, insurers and regulators.
How P3i does it for you
- 01
Start with the loss
What it really cost: people, output, customers, reputation.
- 02
Rebuild the event
The sequence, verified line by line.
- 03
Name the immediate causes
The acts and conditions on the day — without stopping there.
- 04
Dig to the basic causes
Why the act made sense and why the condition existed.
- 05
Close the control gap
The management weakness behind it, fixed across every site.
What you receive
Call us when
Free 30-minute case assessment.
Tell us what happened. In confidence, we will tell you what the investigation should cover, how long it will take and what to preserve today.
Questions
What clients ask about this method.
Is this your own method?
It is the structured model we use in every investigation, built on the internationally used loss causation model and adapted for safety, quality, business and information losses.
Does it replace other methods?
No. It is the frame that ties the other methods together, so every finding reaches a control gap the organisation can fix.
Does it only apply to safety?
No. The same layers work for quality, customer, information, contract and time losses.
Follow the chain. Fix the system.
