Environmental Engineering Reference
In-Depth Information
have.happened?”.If.the.answer.is.“no,”.then.the.event.should.be.excluded.because.
it.is.not.relevant.to.the.accident..If.the.answer.is.“yes,”.then.the.event.stays.because.
it is.signiicant..This.question.should.be.asked.for.each.of.the.events.you.have.shown.
The.Signiicant.Events.and.the.Events.and.Conditions.that.allowed.the.Signiicant.
Events.to.occur.are.the.accident's.Causal.Factors..Once.all.the.signiicant.events.have.
been.identiied.and.all.the.Events.and.Conditions.that.do.not.belong.in.the.analysis.
have.been.excluded,.then.an.examination.of.the.Events.and.Conditions.preceding.the.
signiicant.event.should.be.examined.by.asking.a.series.of.questions.
These.questions.should.include
•.
Why.did.the.event.happen?
•.
What.Events.and.Conditions.led.to.the.occurrence.of.the.event?
•.
What.went.wrong.to.allow.the.Event.to.occur?
•.
Why.did.these.Conditions.exist?
•.
How.did.these.Conditions.originate?
•.
Who.had.responsibility.for.these.Conditions?
•.
Are.there.any.relationships.between.what.went.wrong.in.this.event.chain.
and.other.Events.and.Conditions.in.the.accident.sequence?
•.
Is.the.signiicant.event.linked.to.other.Events.or.Conditions.that.may.indi-
cate.a.more.general.or.larger.deiciency?
This. questioning. should. then. be. repeated. for. each. and. every. event. and. condi-
tion,.where.applicable,.and.reviewed.by.others.to.ensure.that.nothing.has.been.over-
looked.. Once. everyone. has. agreed. on. all. the. results. of. the. questioning,. then. your.
Causal.Factor.Analysis.is.complete.
cAusAl FActor Worksheets
Accident.causes.can.be.broken.down.into.seven.different.“categories”:.equipment/material.
problems,.procedural.problems,.personnel.error,.design.problems,.training.deicien-
cies,.management.problems,.and.external.phenomenon..These.categories.are.further.
broken. down. into. subcategories. to. further. explain. the. cause. of. the. accident.. The.
causal.categories.and.cause.codes.can.be.found.in.Chapter.8,.Table 8.2..These.causal.
categories.are.used.in.a.causal.factor.worksheet.found.in.Appendix.C..Each.work-
sheet.has.a.matrix.that.is.used.to.list.and.identify.the.direct.cause,.the.root.cause,.
and.any.contributing.causes.the.accident.may.have..As.can.be.seen,.each.subcategory.
is. found. within. the. matrix. and. there. is. enough. room. to. list. four. (I. through. IV. in.
Appendix.C).causes.for.each.of.the.subcategories.
These.worksheets.are.broken.down.by.irst.determining.if.that.particular.cause.
was.applicable.or.nonapplicable;.then.the.subcategories.are.to.be.used.to.distinguish.
what.was.the.direct.cause,.the.contributing.cause,.and/or.the.root.cause..There.is.also.
space.to.write.the.cause.descriptions.and.any.recommended.corrective.actions.that.
can.be.taken.
There.are.seven.worksheets.for.major.cause.categories,.and.there.is.an.additional.
worksheet,.found.at.the.end.of.the.seven,.to.put.all.causes.into.summary.form.cre-
ating. one. easy-to-look-at. form.. It. contains. one. direct. cause,. one. root. cause,. and.
