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This Article proposes the use of Root Cause Analysis (RCA) as a tool for reducing or preventing officer-involved shootings (OIS). RCA is a method of problem solving designed to identify core underlying factors that contributed to generate an undesirable outcome, organizational accident, or adverse event. Once these core underlying causative factors have been identified, participants in the system can fashion remedies that will prevent future occurrences of similar undesirable outcomes. RCA is part of a prospective, non-blaming “systems approach” to preventing error in complex human systems that has been successfully used to reduce errors in aviation, healthcare, manufacturing, nuclear power, and other areas.

RCA is not a substitute for current mechanisms for accountability and remediation (e.g., internal affairs, OIS administrative reviews, civil rights litigation, civilian review boards, etc.) Rather, RCA serves as a necessary complement to those retrospective mechanisms, providing a forward-looking form of event review focused on community and officer safety, seeking to prevent future undesired outcomes and gradually improving the safety of a system through targeted reforms over time.

We describe the principles of RCA, its application to evaluate OIS, and explore the limitations of existing review mechanisms, and we provide an example of how RCA might function in reviewing an OIS.


Law enforcement, public safety, police-civilian interactions, officer-involved shootings, OIS, root cause analysis, RCA, quality management and improvement, organizational system design, error prevention, retrospective accountability

Publication Title

Villanova Law Review

Publication Citation

62 Vill. L. Rev. 883 (2017)