March 3, 2009 | Mark Paradies

Root Cause Analysis Tip: Failed Safeguards = Causal Factors

Watch this video…


(Click to watch. Quicktime ,mov format.)

Now ask…

What was the Hazard (energy).

What was the Target?

What were the Safeguards?

Failed Safeguards are often directly linked to Causal Factors. A good way to identify the Causal Factors after an accident is to perform a Safeguard Analysis (as you did when you answered the questions above) and then ask these five questions:

1. What error allowed a Hazard or allowed it to grow too large?

2. What error allowed a Safeguard to fail?

3. What error allowed a Safeguard to be missing?

4. What error allowed a Target to get too close to a Safeguard?

5. What error allowed an Incident to become worse after a Hazard contacted a Target?

Asking these questions after a Safeguards Analysis often leads to a much more thorough development of the Causal Factors of an incident/accident.

These questions are depicted on the accident model diagram below.

(Copyright 2008 by System Improvements, Inc. Used by permission.)

For more information about using Safeguards Analysis to identify Causal factors, see Chapter 10 of the new TapRooT® Book available at

To learn more about advanced root cause analysis techniques and to practice using the techniques on lifelike accident examples, attend TapRooT® Training. For more information, see:

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