Accident Causal Factors Chart

Causal Factors Identification of Factors Possible Corrective Actions 

Environmental Unsafe Hazardous processes management failed Job hazard analysis or formulation of 

Defective, overused Buildings, machines, or equipment worn, cracked, broken, or defective Inspection replacement proper maintenance 

Improperly guarded Work areas, machines, or equipment that are unguarded or inadequately guarded Inspection check plans, blueprints, purchase orders, contracts, and materials provide guards for existing hazards 

Unsafe dress or apparel Management failed to provide/specify the use of goggles, respirators, safety shoes, hard hats, or safe apparel Provide proper apparel or personal protective equipment specify acceptable dress, apparel, or protective equipment 

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The book includes helpful resources in the appendices, such as a nurse safety perception survey, an accident causal factor chart, sample ergonomics symptoms report, sample TB exposure control plan, and a model respirator plan for small organizations. Complete with review exercises in each chapter, this book is ideal for certification training in nursing programs and as a reference for developing nursing in-service safety sessions. 

The event and causal factors charts used by the Department of Energy as an accident (or mishap) investigation tool is basically the same tool as multilinear event sequencing (MES) and similar to simultaneous timed event programming (STEP)—all based on concepts of Ludwig Benner. It is also called causal factors analysis (CFA). 

During the operations phase, new hazards are identified by periodic inspections, worksite monitoring, audits, and appraisals. Techniques used to identify hazards during the operations phase include checklists, PET analysis, and safety studies. Accident analysis is also an important method of detecting previously undetected or uncorrected hazards. Accident analysis tools include change analysis, PET analysis, MORT and mini-MORT analysis, and event and causal factors charts. 

Techniques recommended for conducting accident analysis include change analysis, event and causal factors charts, PET analysis (or MORT or mini-... 

The accident analysis report is a narrative. It includes a description of the project and the accident, a summary of findings and recommendations, an outline of methodology, and a detailed discussion of facts, findings, and recommendations. Photographs, drawings, and an event and causal factors chart are included as illustrations. 

In addition, Bill Johnson used a scroll as a normally expected event and an oval as a satisfactory event. The normally expected event distinguishes events that are typically a part of any system, such as change and normal variability. The satisfactory event describes events that may be accident causal factors but are a necessary part of the operation, like functional (part of the system) people or objects in the energy channel. Also, in addition to using the traditional transfer symbol (a triangle), the MORT chart includes capital letters as drafting breaks and small ellipses as risk transfers (Fig. 18-3). 

After completely evaluating the chart, cross-check results with the event and causal factors chart and change analysis. Reconcile any differences, use all three tools to aid in writing the formal accident report, and be careful to provide findings, conclusions, and recommendations (backed up with evidence) for each factor deemed to be less than adequate. 

Event and causal factors charts are graphic representations that basically produce a picture of an accident—both the sequence of events that led to the accident and the conditions that were causal factors. This tool works very well in conjunction with PET or MORT analysis and is used widely in the Department of Energy. 

The purpose of the event and causal factors chart is to provide a systematic accident analysis tool to aid in collecting, organizing, and depicting accident... 

Like other accident analysis techniques, the event and causal factors chart should be initiated as soon as the investigation begins and developed as evidence is collected. A detailed chart is developed during the investigation it is then reduced to an executive summary containing only key events and causal factors to serve as a report illustration. 

Start the event and causal factors chart as early as practical. From the available information, make an event note or card for each event that occurred during the accident sequence and a condition card for each relevant condition that is identified. Organize and reorganize the cards as more information becomes available. 

Event and causal factors charts can be relatively simple and straightforward. The complexity of the chart is determined by the complexity of the accident and the desired level of detail. 

Figure 19-3 Example of an event and causal factors chart. This executive summary version of the chart would be included in the formal accident report and used as a briefing tool.

Develop an accident chronology (e.g., events and causal factors chart) while collecting evidence. 

Whether using a manual or computerized approach, the process begins by chronologically constructing, from left to right, the primary chain of events that led to the accident. Secondary and miscellaneous events are then added to the events and causal factors chart, inserted where appropriate in a line above the primary sequence line. Conditions that affect either the primary or secondary events are then placed above or below the events. 

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