Causal Factor Analysis - Accident/Incident Prevention Techniques - page 143

up.to.three.contributing.causes,.their.descriptions,.and.any.corrective.actions..The.
.contributing. causes,. which. should. be. listed. and. have. corrective. actions,. are. those.
that. can. result. in. the. most. effective. beneit. when. corrected.. Although. only. three.
contributing.causes.can.be.reported,.and.their.corrective.actions.reported,.corrective.
actions.should.be.made.on.all.identiied.causes.
summAry
Causal.Factor.Analysis.is.a.useful.tool.when.trying.to.understand.why.an.accident.
occurred..It.is.used.when.there.are.multiple.problems.and.the.Event.Factor.Chain.is.
long.or.complex..After.investigating.an.accident.and.collecting.all.the.information.
surrounding.an.accident,.an.event.chain.technique.can.be.used.to.help.understand.
and. visually. depict. why. the. accident. occurred.. This. is. done. by. asking. a. series. of.
questions,.eliminating.all.events.and.conditions.that.are.not.signiicant,.and.keep-
ing.those.that.are.signiicant..Once.all.the.events.and.conditions.that.belong.to.the.
accident.have.been.determined,.another.examination.can.be.performed.on.the.events.
and.conditions.that.remain..The.second.questioning.process.can.help.in.understand-
ing.why.the.accident.occurred.and.in.inding.out.ways.to.help.prevent.this.accident.
and.similar.accidents.from.recurring.in.the.future..Answers.should.then.be.reviewed.
by.others.to.gain.more.insight,.and.reassessments.should.be.made.where.applicable..
Conclusions.should.then.be.drawn.
Worksheets.can.also.be.used.to.help.identify.the.direct.cause,.the.root.cause,.and.
any. contributing. causes. of. the. accident.. The. results. from. the. worksheets. are. then.
placed.on.a.summary.worksheet.along.with.the.cause.descriptions.and.any.recom-
mended.corrective.actions..From.this.point.on,.appropriate.changes.can.be.made.to.
help.prevent.that.accident.or.any.similar.accident.from.occurring.in.the.future.
reFerences
Buys,.J..R..and.J..L..Clark.. Events and Causal Factors Charting, .System.Safety.Development.
Center.. (SSDC-14). .Idaho.Falls,.ID:.EG&G.Idaho,.Inc.,.August.1978.
United.States.Department.of.Energy..Ofice.of.Nuclear.Energy.. Root Cause Analysis Guidance
Document. .Washington,.D.C.:.U.S..Department.of.Energy,.February.1992.