Causal factor analysis direct cause

On the downside, causal factor analysis is time consuming and requires the investigator to be familiar with the process for it to be effective. As can be seen later in this chapter, the accident scene may need to be revisited a number of times and areas that are not directly related to the accident may need to viewed, in order to have a complete event and causal factor chain. It requires a broad perspective of the accident in order to identify any hidden problems that would have caused the accident. 

Identifying the direct cause of an accident is optional because it is not necessary to complete a causal factor analysis. However, the direct cause should be identified... 

Identifying the direct cause of an accident is optional because it is not necessary to complete a causal factor analysis. However, the direct cause should be identified when it facilitates understanding of why the accident occurred, and it is useful in developing lessons learned fiom the accident. The direct cause is also used when writing up the accident report and filling out an accident report form. 

The purpose of the Root Cause Analysis is to identify causal factors relating to a mishap or near-miss incidents. The technique goes beyond the direct causes to identify fundamental reasons for the fault or failure. 

Accidents are usually complex and are the result of multiple causes. A detailed analysis of an accident will normally reveal three cause levels basic, indirect, and direct. At the lowest level, an accident results only when a person or object receives the release of an amount of energy or exposure to hazardous material that cannot be absorbed safely. This energy or hazardous material is the direct cause of the accident. The second causal areas are usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the indirect causes or symptoms. In turn, indirect causes are usually traceable to poor management policies and decisions, or to personal or environmental factors. These are the basic causes. 

The direct and indirect methods may be applied to single case studies as well as to frequent cases. The single case study of an accident is the method most frequently employed. The analysis of contributing factors follows a job-specific, implicit causal model. With respect to the frequency of their use factors are rank-ordered into behavior-related, technical, and organizational causes. Objectives are ... 

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