October 4, 2023 | Justin Clark

Identifying Causal Factors – Advanced Skills

Here are a few hot-button topics with identifying Causal Factors. Any difficulty identifying Causal Factors comes from not applying the definition, the whole definition, and nothing but the definition.

–Causal Factor –

a mistake, error, or failure that directly leads to or causes an incident,
or fails to mitigate its consequences.

We’ll walk through a fictional example below:

Key Concept 1: It has to be a MISTAKE.

Causal Factors are associated with missing safeguards. Welder 1 started welding is not a mistake but an expected action. It’s not a Causal Factor.

Shutting down operations and closing up shop is the single most effective way to prevent all accidents, AND it’s a level 1 safeguard:

For 35 years, we’ve been assuming that the business is going to continue operating. I can remove the event “employee arrives at work,” though, and prevent every single job-site incident. Not useful.

Key Concept 1: Causal Factors have to be mistakes, errors, or failures.

If we fixate on the “could have prevented the incident” portion, we end up blaming individuals who did everything correctly.

———

Key Concept 2: Causal Factors cannot contain other causal factors.

If you find yourself with something like this,

you have only identified one true Causal Factor, and the other two

Contributed to another event and don’t belong here,
Are Near Root Causes or Root Causes, or
Aren’t mistakes, errors, or failures.

If the answer to “what happened because of this mistake” isn’t the incident itself, it’s not a causal Factor.

Key Concept 2: Causal Factors directly lead to the incident.

——-

Key Concept 3: Root Causes are NEVER Causal Factors; they lead to Causal Factors.

Examples of Root Causes frequently misidentified as Causal Factors; these are never Causal Factors:

What a Pre-Job Briefings missed
Inadequate Procedure steps
Not following the procedure
Improper training
Poor work culture
Distracted operator

Key Concept 3: if it’s on the back of the Root Cause Tree® Diagram, it’s not a Causal Factor.

In my fictional example, there is an equipment failure and three missing safeguards associated with the three Causal Factors:

Overcharging the battery is an equipment failure
The system to remove accumulated explosive gases was offline
Continuous Atmospheric Monitoring was offline
No backup atmospheric monitoring tests were conducted.

All three Key Concepts can be properly applied if you keep the definition of a Causal Factor always handy, as we do in the software (hover over the CF symbol: