Causal factor defined

A number of deductive techniques require that the investigation team develop a tree. This is accomplished by reasoning to organize causal factors into a diagram (tree) and define their interrelationship. These logic... 

It helps to define two terms to understand the hierarchy of sequencing for the occurrences that make up an incident. The most widely accepted terms are causal factor and root cause ... 

The first step in developing a causal factor chart is to define the end of the incident sequence. Construction of the chart should start early from the end point and work backward to reconstruct what happened before the incident by identifying the most immediate contributing events. 

Prospective study. A rather loose term which may, perhaps, be defined as a study in which the measurement of the presumed causal factors is both temporally and logically prior to the measurement of the outcomes of interest (the presumed effect )- In this sense the term applies to clinical trials and also to many cohort studies. 

It is not good science to use terms that cannot be defined. Definitions of the terms unsafe conditions and unsafe acts that can withstand thorough inquiry are scarce. I believe that the terms unsafe act and unsafe condition should be eliminated from the vocabulary of safety professionals, to be replaced by terms such as causal factors or risk factors—which can be defined. Safety professionals should also cease using their dominoes or the falling domino idea They are overly simpMstic representations of incident causation. 

Define in your own words the following basic causal factor categories ... 

On each branch item, or main factor, determine the detailed factors. Defining and linking the relationships of the possible causal factors should lead to the source of the quality characteristic. 

On a scale of 1 to 10, with 10 being the highest score, some of these companies—large companies—scored as low as 2. Causal factor determination was abysmal, corrective actions were superficial, and opportunities to select leading indicators that define how safety management systems could be improved were overlooked. 

When there is a lack of understanding about the fundamentals of incident causation and the need to identify root causal factors, supervisors, upper levels of management, and safety professionals sign off on incident reports when the reality is that those investigations were shallow and of little value. Making the additional reviews proposed here will help a safety professional define the extent of any problem and assist in crafting a course of action for improvement. 

A key finding of the Columbia Accident Investigation Board (CAIB) report is that the lack of an adequate safety culture in NASA s space shuttle programs was a causal factor in the catastrophic loss of the Columbia orbiter and crew. While safety is not directly defined by the CAIB, the report suggests that (1) the culture of the program led to inadequate safety practices (2) this breakdown of safety culture led to the toleration of a pattern of problems with the foam debris (3) foam debris was the... 

A hazard is a wrapper containing (or describing) all of the latent conditions (or components) necessary to result in a mishap, when the latent factors actualize. And, the hazard wrapper also describes the mishap outcome to be expected. The major difference between a hazard and mishap description is how they are stated a hazard could happen whereas a mishap did happen. In addition, a hazard is stated with all the necessary elements as a potential condition, while a mishap is only stated as the final outcome (which is defined in the hazard statement). It is interesting to note that when a mishap actually does occur, it is the job of the accident investigation team to discover all of the mishap causal factors, which in effect describes the hazard components that should have originally been identified. 

We first focus on criteria developed from feedback-control theory. Efficient control requires a reliable measurement and feedback of performance. Reliability is here defined as the extent to which repeated measurements give the same results. A reliable reporting and counting of accidents is important if the frequency of accidents (number of accidents per one milHon hours of work) is used as a measure of the SHE performance of the company or department in qnestion. Another example has to do with whether different investigators who look into the same accident will come up with the same results concerning causal factors (intra-observer reliability). 

An advantage of these types of application is that the results will immediately become available in a database for statistical analyses and for follow-up. Computer support is best suited for companies where the accidents mainly fall within a few well-defined categories. The program must not be too closed in the sense that it makes the investigator overlook vital information and uncommon causal factors. 

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