A complete root cause analysis will reveal all the antecedent events leading up to and explaining the consequent event.

However, the QA SysOp Investigation Report provides space for coding two of those antecedents:

• The first action or decision that eventually led up to consequent event
• The action or decision considered by the QA SysOp to be most significant or critical for that organizations process

The initial antecedent may or may not also be considered the most significant.