October 17, 2012 | Barb Carr

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 TapRooT� 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 TapRoot� 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.� 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.� We are just stating the facts.

REMINDER 2:� 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 Tree�.� This could be one of the roots causes as to why an operator grabbed the wrong valve.� We would fix the lighting issue and not the operator.� 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.� You have to go to a TapRooT� Course to learn these techniques.

Often when using the methods above you realize that you had not even identified a Causal Factor.� In fact, it might not even be on your SnapCharT� 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.)

Show Comments

4 Replies to “Root Cause Tip: What’s a Causal Factor?”

  • 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.

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