Root Cause Analysis Tip: Failed Safeguards = Causal Factors
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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.
For more information about using Safeguards Analysis to identify Causal factors, see Chapter 10 of the new TapRooT® Book available at http://www.taproot.com/store.php.
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: