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Initial findings were sorted based on commonalities and reduced to entry lines; the 5-Whys methodology was adopted to explore the cause-and-effect relationships underlying each problem. Immediate Causes, Underlying Causes and Root Causes were identified and summarized in this report with a set of recommendations. Root Causes and Underlying Causes were identified by the review team and a fault tree diagram generated.
Recommendations were provided primarily in relation to the Root Causes, and secondarily towards the Underlying and consequent Immediate Causes. A summary of most important recommendations to address these Root Causes had been provided, together with an assessment of their (ease of) implementation and impact. The complete set of findings, their Immediate, Underlying and Root Causes, and corresponding recommendations were added.
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