May 6, 2009 | Barb Carr

Root Cause Analysis Tip: Defining a Casual Factor…Just What Caused the Incident or What Made the Incident Worse?

The answer to “What caused the Incident or What Made the Incident Worse,” is BOTH. Why you may ask? Look at the video below, think about the Causal Factors and tell me what errors caused the Incident and what made it worse.

Rough Morning
There are many Potential Improvement Opportunities (PIO’s) following an Incident. Just focusing on the items that caused the incident is a lost opportunity. Take a fire for instance, we all know that there will be human performance or equipment failure errors related to the fire triangle (oxygen, fuel source, and ignition)… but what if the fire department responded late or not at all?

Now that you know the best way to defining Causal Factors during an Incident, what would you do with problems found that did not cause or make the Incident worse? These problems are also a PIO. You will not use these findings to reduce or prevent the Incident Casual Factors but you will follow up as you would an Audit.

Let’s say we found out that the Company Management Contact Roster was outdated during the fire investigation but the employees did call the fire department as required. Now this is not a Causal Factor but could be a Significant Issue if I needed the Senior Manager to quickly make a decision for production or shutdown…. now that would definitely need to be fixed.

If these thoughts are new to you and one of our experienced TapRooT ® User’s has showed you this article, check out our course time and location link for your Potential Improvement Opportunity:

If your are an Experienced TapRooT ® User and want to see how to polish your Defining Causal Factors skills using advanced techniques, join us at the Summit and take it to the next level: TapRooT® Advanced Techniques

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