What is Root Cause Analysis (RCA)?

Root Cause Analysis (RCA) is a systematic process used to uncover the underlying organizational reasons why a psychological injury or mental health incident occurred. Rather than stopping at "human error" or an individual's inability to cope, RCA digs deeper to find the systemic factors—such as job design, leadership behaviours, or resource allocation—that allowed the incident to happen.

The impact of performing RCA is the transition from reactive fixing to proactive prevention. In a PHS-IMS, if an employee experiences burnout, an RCA looks at the workload management system, the level of support from supervisors, or the "always-on" culture that created the conditions for that burnout.

Root Cause Analysis and How it Relates to the PHS Standard (CSA Z1003 / ISO 45003)

Under the CSA Z1003 and ISO 45003 standards, RCA serves as the component of incident investigation and the "Act" phase of the management system. These standards require a structured approach to understanding why a psychological injury occurred, ensuring the focus remains on organizational factors rather than individual traits.

Investigation must prioritize Psychosocial Factors. This PHS-informed lens allows the organization to identify whether the work environment itself contributed to the incident, probing root causes rather than merely addressing surface-level symptoms.

The primary goal of any RCA is to prevent recurrence through the implementation of permanent changes. Ideally, these interventions sit at the top of the Hierarchy of Controls, focusing on the elimination or substitution of hazards whenever possible. RCA must also determine if existing Administrative Controls were followed or if those controls require optimization.

Documenting and executing these changes ensures that a similar injury does not happen to another employee, effectively fulfilling the organization’s legal and ethical obligations to provide a safe workplace.

Why Root Cause Analysis Matters for Leaders & HR

Root Cause Analysis (RCA) represents the gold standard for fulfilling the Duty of Care and establishing a solid record of Due Diligence. This process shifts the focus from superficial fixes to meaningful, structural changes that protect both the employee and the organization.

Documenting a thorough RCA provides evidence of Reasonable Care during a regulatory investigation. It proves that the organization is genuinely committed to improving the work environment. This level of transparency shows authorities that leadership takes its legal obligations seriously and is actively working to mitigate psychosocial hazards at their source.

A transparent RCA process reinforces the Internal Responsibility System (IRS) by creating a culture of accountability rather than blame. When employees observe that their reports lead to tangible systemic changes, trust in leadership grows.

How to Conduct Root Cause Analysis in Your Organization

A Psychological Health and Safety (PHS) informed RCA avoids the "Blame Game" and focuses instead on the "System Game." Using the 14 Psychosocial Factors as a diagnostic guideline helps identify whether an incident stemmed from a lack of "Involvement and Influence" or perhaps a breakdown in "Psychological Manager Support."

Involving the Joint Health and Safety Committee (JHSC) provides a frontline perspective during this analysis. The final step requires leadership to document findings and loop them back into the broader management system. Updating PHS-IMS policies ensures that the organization remains resilient against future psychosocial hazards.

iMindify PHS Expert Insight: Using the "5 Whys" for PHS

When a psychological injury occurs, the IRS requires us to look past the individual. Use this "5 Whys" framework to find the real hazard:

By identifying the root cause, you can implement a systemic Administrative Control that re-evaluates project intake when staffing changes. That is how you fix the system.