September 18, 2019 | Mark Paradies

What is a Causal Factor? (Updated)

What is a Causal Factor?

The term “Causal Factor” came from the System Safety Development Center in Idaho Falls, Idaho. It was part of an investigation tool called “Events and Causal Factors Charting.” We got permission to use the tool and the original documentation in 1988 as part of the original version of TapRooT®. But as time went on, we simplified and modified the tool and eventually renamed it “SnapCharT®.” When we did that, we decided we needed to define a “Causal Factor.” Our definition is:

Causal Factor:
A mistake, error, or failure that directly leads to
(or causes) an Incident (the circle on the SnapCharT®) or
fails to mitigate the consequences of the original error.

How to Find a Causal Factor

Our Causal Factor definition has served us well but, over the years, we have taught several different methods of identifying Causal Factors. These methods include:

  • Direct observation
  • The “so what” method
  • Safeguard Analysis
  • The three-question method

But this Autumn we will start teaching a new method to find Causal Factors. What is it? A set of questions to ask depending on the type of incident you are investigating.

Causal Factor Worksheets

What type of questions sets (worksheets) did we develop?

  • One for Equipment Failure-related Incidents
  • One for Patient Safety-related Incidents
  • One for Quality-related Incidents
  • One for Safety-related Incidents

If you have an incident that doesn’t fit one of these categories, you can:

  • Go back to the Three Question Method
  • Use the check sheet or sheets that most closely match your Incident.
  • Develop a custom check sheet based on the other sheets and the Three Question Method

Safety Causal Factor Worksheet

What does a Causal Factor Worksheet look like? Here is a draft of the Safety Causal Factor Worksheet:

Learn More About Causal Factor Worksheets

Want to learn more about these Causal Factor Worksheets? Attend the 2020 Global TapRooT® Summit and go to the Using Causal Factor Worksheets best practices session in the Improving Investigations Track. Alex Paradies and Tim Diggs will teach you to use these new tools.

When is the 2020 Global TapRooT® Summit being held? March 9-13.

Where is the 2020 Global TapRooT® Summit being held? The Horseshoe Bay Resort near Austin, Texas.

How much does it cost to attend? See below to attend just the Summit (March 11-13) or the Summit and a Pre-Summit Course (March 9-13)…

Don’t forget, this is a Summit where you are guaranteed to learn.


Attend the 2020 Global TapRooT® Summit. Go back to work and implement your road map to success. If you don’t save 10 times the cost of your attendance at the Summit, let us know and return your Summit materials and we will refund 100% of the Summit registration fee. This guarantee shows how certain we are that you will learn valuable best practices to take your facility’s performance to the next level.

Now is the time to register. Use the link below…

Note: The Safety Causal Factor Worksheet above is copyrighted material and is used here by permission. Duplication is prohibited.

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Show Comments

6 Replies to “What is a Causal Factor? (Updated)”

  • Keith says:

    Whether it is a JSA, or PSM function there is a plan for the procedure and one step can Injure or Kill.
    Example: in the late 60’s/ early 70’s a military person was tasked to DISARM an Ejection seat.
    He missed one step on the checklist; because he was either not listening or was working by himself. It was the most serious form of injury you could survive. A metal cartridge housing, attached to a small drogue chute, attached to the main parachute was deployed while he was directly over the assembly. The injured person sustained a permanent disfiguration.
    For me it was a formal Learned From Incident Lesson; I had to preform similar tasks daily.

  • Chris says:


    Definitely agree on the one step can kill you. As an ex-air force fuels mechanic, I know the F-4 ejection seat was notorious for safe’ing issues. Could have used not just procedural issues but also human engineering redesign solutions.

    The problem is whether a JSA or PSM was required on site and just used as a memory jogger or if the steps were written and required to be read while doing the job.

  • Andrew Morton says:

    What’s the meaning of NI?

  • Chris Vallee says:

    Hi Andrew,

    In our process, NI is defined as needs improvement.

  • Alfons Salmhofer says:

    Great refresher on what a “causal factor is!”

    We are getting all the RCA incident reports from our projects here in our HQ and from what I see, many investigators (TapRooT trained) struggle with the correct identification of causal factors.

    This in turn leads to the development of ineffective corrective actions, or corrective actions that have no relevance to the real cause. Identifying the correct causal factor is key to an effective root cause analysis and investigation.

    My two cents…

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