Root Cause Tip: What’s a Causal Factor?
By this time, many of you see Causal Factors everywhere you look; can’t help yourself, your brain just works that way after taking a TapRooTï¿½ Root Cause Analysis Course. Every once in a while, your brain also needs a quick jumpstart. Thus, today’s topic covers “What’s a Causal Factor” and “What is not a Causal Factor.”
In our TapRootï¿½ Courses we define a Causal Factor as either an action or lack of action that caused an Incident or made the incident worse. Basically it boils down to following:
An action someone performed.
An action, a piece of equipment, component or process transaction performed.
An action not performed by someone.
An action not performed by piece of equipment, component or process transaction.
REMINDER 1: This is not saying we are blaming the person, piece of equipment, component or process transaction.ï¿½ We are just identifying the actions or lack of actions that had to be present for the incident to occur or get worse.
For example, a person may have followed a procedure perfectly and still created the ignition that ignited the fuel vapor.ï¿½ We are just stating the facts.
REMINDER 2:ï¿½ We do not fix Causal Factors, we fix Root Causes that allowed or failed to prevent the Causal Factor from happening.
For example, “Lights NI” is one of our Root Causes on the Root Cause Treeï¿½.ï¿½ This could be one of the roots causes as to why an operator grabbed the wrong valve.ï¿½ We would fix the lighting issue and not the operator.ï¿½ Fixing the lighting will help the operator more successful in his/her task.
REMINDER 3: Use the Four Step Method and the Safeguard Error Questions to help define the Causal Factor.ï¿½ You have to go to a TapRooTï¿½ Course to learn these techniques.
Often when using the methods above you realize that you had not even identified a Causal Factor.ï¿½ In fact, it might not even be on your SnapCharTï¿½ yet.
Let me if these tips help.
If you like root cause analysis tips, you may be interested in viewing a short video in our free series:
What Makes a World-Class Root Cause Analysis System (Click here to view ten minute video.)
Doing Better Investigations (Click here to view six minute video.)