Root Cause Tip: Causal Factors – Initiating Errors and Stop/Catch/Mitigate
The TapRooT® Definition of a Causal Factor is:
“A mistake, error, or failure that directly leads to (or causes) an Incident or fails to mitigate the consequences of the original error.”
This definition is one major thing that distinguishes TapRooT® from some other methods. We don’t just find the first thing that went wrong, we find EVERYTHING that went wrong. I’ve had people say to me that “but if I fix the first problem the incident would not have happened.” That is actually true, but if I only focus on the first thing that went wrong (which is sometimes the most obvious), then I do not address everything else that is wrong with my system. It also allows people to fall into the trap of determining “the causiest causal factor” and ignoring everything else.
Consider this diagram:
Is It Possible to Have an Incident with Only One Error?
Yes. But more often than not, once we’ve made a mistake, we have chances to stop/catch the problem before it becomes an incident. We also sometimes have chances to mitigate the consequences.
So when looking for Causal Factors, I find the first error/failure (initiating error), and they look for chances to stop/catch/mitigate. Each time I fail to stop/catch/mitigate, it is a new Causal Factor.
You will also notice that we could have an initiating error later in the timeline was well. It could be completely unrelated but allowed the hazard to reach the target.
Here is an example:
*Someone turns the wrong valve and allows a hazard (this is an initiating error).
*A second check of the valve configuration was not completed as required (a chance to stop/catch the first error).
*Someone lights a cigarette in an unauthorized area (another initiating error).
*Emergency response team did not arrive for 30 minutes (chance to mitigate the consequences).
Each one of these would be a Causal Factor.
Defining Causal Factors Does Not Have to Be Difficult
The more you do it, the more comfortable you will be. I find that the concept of stop/catch/mitigate can really be helpful in making sure you find ALL the problems that led to an incident.
So thanks for visiting our blog. I hope you don’t have an incident anytime soon, but if you do, I hope you find this information helpful. If you’re interested in learning more about identifying causal factors and finding the root causes of incidents, register for our 2-Day TapRooT® Root Cause Analysis Training.