Contributory causal factors

The injury, dysfunction, or other putative effect of the toxicant must be regularly associated with exposure to the toxicant and any contributory causal factors. 

Analysis At the outset of this chapter, I drew a distinction between the foreground precipitating cause of a phenomenon of interest and various background contributory causal factors that, although they did not themselves trigger the phenomenon, helped set the stage for another factor to precipitate its... 

In effect, he acknowledged that workers raised in an agricultural society had been hired to work in an industrial-society factory. Consequently, there was a mismatch between the entrenched behavioral and mental habits of many of the new workers and the mental and behavioral requirements for operating such a factory safely. This is the first reason why the location of the Bhopal plant was a contributory causal factor in the Bhopal disaster. 

The second reason why locating the pesticide factory in Bhopal proved to be a contributory causal factor to the disaster involves ineffective zoning. As noted, originally UCIL did not manufacture Sevin at the Bhopal plant. It imported pure Sevin and diluted, packaged, and... 

Pareek ako pointed to the culture of broader Indian society as a contributory causal factor We Indians start very well, but we are not meticulous enough to follow up adequately. Ibid. Lewis (2004), 03 38-03 55. 

In several of the cases considered, a key contributory causal factor in the engineering misconduct that occurred was that the engineering design or production work done was in some sense or other decontextualized. The people who carried it out may have an overly narrow context in mind when doing their design work (Cadillac). This may lead them to overlook problematic consequences of their work that stem from interactions with elements left outside that narrow system context. Alternatively, engineers involved may not take carefully into account how their products will be made or for what purposes they will be used in the actual social contexts of production and use. This can have serious unexpected negative consequences (Bhopal, Topf Sons). 

Although not necessarily intended, such report formats lead to identification of a single causal factor, usually the unsafe act, rather than stressing the concept of multiple causation. Sometimes—but only sometimes — a contributory causal factor was also identified. 

Change analysis o) (also known as Change Evaluation/Analysis, CE/A) is another tool that can assist the identification of causal factors. It is useful for brainstorming about what has changed since conditions were safe, or perceived as safe. It may also be used for hypothesizing potential contributory factors to a hazardous condition or action. 

Root (or primary) causes, immediate (or secondary) causes, and contributory factors are identified, analyzed, and discussed in this section of the report. As described in Chapter 9, process safety incidents are the result of many factors, and therefore singling out one cause is rarely the proper approach. Some experts indicate that if a fault tree or causal factor chart was developed as part of the investigation it should be incorporated to facilitate understanding. 

Using contributory factor framework, cause and effect method, tree diagram, barrier analysis and the five why s technique. Each contributory factor identified in the analysis could be a causal factor or an influencing factor... 

Several attempts have been made to graft systemic factors onto event models, but all have important limitations. The most common approach has been to add hierarchical levels above the event chain. In the seventies, Johnson proposed a model and sequencing method that described accidents as chains of direct events and causal factors arising from contributory factors, which in turn arise from systemic factors (figure 2.7) [93]. 

Developing the actual (as opposed to what people believe occurred) sequence of events is crucial. Various safety analysis techniques discussed in Chapters 5 through 9 are excellent methods to use in attempting to reconstruct a timeUne of activities. These tools are also very useful for linking accident sequences to sequence causes. The analysis should clearly indicate primary, contributory, and other causal factors that led to the accident. 

Error analysis techniques can be used in accident analysis to identify the events and contributory factors that led to an accident, to represent this information in a clear and simple manner and to suggest suitable error reduction strategies. This is achieved in practice by identification of the causal event sequence that led to the accident and the analysis of this sequence to identify the root causes of the system malfunction. A discussion of accident analysis techniques is included in Chapter 6. 

Human error can be a significant cause or contributory factor in many hazards. For this reason, it is imperative that system safety evaluate all man-machine interfaces (MMIs) and human tasks for possible hazards, particularly in safety-critical applications. The most common human error causal categories are listed in Table 2.11. 

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