Environmental Engineering Reference
In-Depth Information
9
CausalFactorAnalysis
IntroductIon
Accidents.are.rarely.simple.and.almost.never.result.from.a.single.cause..They.may.
develop. from. a. sequence. of. events. involving. performance. errors,. changes. in. pro-
cedures,. oversights,. and. omissions.. Events. and. conditions. must. be. identiied. and.
examined.in.order.to.ind.the.cause.of.the.accident.and.a.way.to.prevent.that.accident.
and. similar. accidents. from. recurring.. To. prevent. the. recurrence. of. accidents,. one.
must.identify.the.accident's.causal.factors..The.higher.the.level.in.the.management.
and.oversight.chain.in.which.the.root.cause.is.found,.the.more.diffused.the.problem.
can.be.
Causal. factor. analysis. is. a. form. of. root. cause. analysis. that. aids. in. the. develop-
ment.of.evidence.by.collecting.information.and.putting.the.information.in.the.logical.
sequence. so. that. it. can. be. easily. examined.. This. will. lead. to. the. causal. factors. of.
the.accident.and.then.to.the.development.of.new.methods.in.order.to.help.eliminate.
hazards.or.causes.of.that.accident.or.similar.accidents.and.prevent.their.recurrence.
in. the. future.. By. creating. an. event. in. the. causal. factor. tree. (chain. or. chart). as. can.
be.seen.in.Figure 9.1,.multiple.causes.can.be.visually.illustrated,.as.well.as.a.visual.
relationship.between.the.direct.and.contributing.causes.can.be.identiied..By.adding.
all.harmful.energy,.events,.exceeded/failed.barriers,.and.people/objects.affected.by.
harmful.energy.that.produced.the.undesired.outcome,.event.causal.charting.also.visu-
ally.delineates.the.interactions.and.relationships.of.all.involved.groups.or.individuals..
By. using. causal. factor. analysis,. one. can. develop. an. event. causal. chain. to. examine.
the.accident.in.a.step-by-step.manner.by.looking.at.the.events,.conditions,.and.causal.
factors.chronologically,.in.order.to.prevent.future.accidents..Worksheets.can.also.be.
used.to.list.the.applicable.causes.and.sub-causes.for.each.category.of.indings..These.
worksheets,.such.as.those.found.in.Appendix.C,.can.then.be.transferred.to.a.summary.
worksheet.for.easy.viewing.
deFInItIon
Causal.factor.analysis.is.used.when.there.are.multiple.problems.with.a.long.causal.
factor.chain.of.events..A.causal.factor.chain.is.a.sequence.of.events.that.shows,.step.
by.step,.the.events.that.took.place.in.order.for.the.accident.to.occur..Causal.factor.
analysis.puts.all.the.necessary.and.suficient.events.and.causal.factors.for.an.accident.
in.a.logical,.chronological.sequence..It.analyzes.the.accident.and.evaluates.evidence.
during.an.investigation..It.is.also.used.to.help.prevent.similar.accidents.in.the.future.
and. to. validate. the. accuracy. of. pre-accidental. system. analysis.. It. is. used. to. help.
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