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Root Cause Analysis: A Tool To Promote Officer Safety and Reduce Officer Involved Shootings Over Time

NCJ Number
Villanova Law Review Volume: 62 Issue: 5 Dated: December 2017 Pages: 883-924
Date Published
43 pages

This article advocates and describes "Root Cause Analysis" (RCA) as a means of promoting officer safety and reducing officer involved shootings (OIS). 


RCA is a method of problemsolving designed to identify core underlying factors, including environmental or systemic factors, that contributed to an undesirable outcome, organizational accident, or adverse event. Once the core underlying causative factors have been identified, participants in the system can develop remedies that will reduce or remove them from the system, so as to prevent future occurrences of an OIS. RCA is a non-blaming approach for analyzing factors that contributed to an OIS or any undesirable event. It has been used successfully in aviation, healthcare, manufacturing, nuclear power, and other areas. Existing OIS review mechanisms are based on retrospective accountability based on a determination as to whether the officer, the individual who was shot, or some third party bears blame. Such measures focus on individual culpability and may deter police from shooting based in deliberate or intentional misconduct; however, this response has failed to reduce the occurrence of accidental or unintentional acts or encounters that result in an OIS. This article advises that RCA is not a substitute for current mechanisms of accountability and prevention. RCA is an objective, non-blaming procedure that aims to analyze all the factors that contributed to an OIS for the purpose of developing policies and procedures that reduce the likelihood of an OIS occurring without compromising public safety. 5 figures and 165 notes

Date Published: January 1, 2017