Reference for Causal Factors and

DESIGNER INCIDENT INVESTIGATION REPORTS, AND A REFERENCE FOR CAUSAL FACTORS AND CORRECTIVE ACTIONS... 

Since personnel who make very few incident investigations in a year would benefit from having a thought prompter, a draft of a Reference for Causal Factors and Corrective Actions is provided. 

At this point, the designer of the form has at least two options. One is to give instructions such as those in items 25 and 26 and provide a separate, detailed Reference for Causal Factors and Corrective Actions. Or, the form designer could select from the Reference for Causal Factors and Corrective Actions those subjects appropriate to operations and enter them directly on the form, preceded by check-off boxes, as a part of items 25 and 26. A form can be designed, albeit using small print, that includes abbreviations of 20 or more of the causal factors and all of the corrective actions included in the exhibit that follows, leaves enough room... 

If a Reference for Causal Factors and Corrective Actions as thorough as the following is to provided, it could be included as pages 3 and 4 of the Incident Investigation Report Form. (In readable print, it can easily be contained in two pages.) Or, it could be a stand-alone reference (peihaps encased in plastic for preservation purposes) to be maintained in a suitable file, or just included in the procedure manual containing the instractions on incident investigation. 

I emphasize that this Reference For Causal Factors and Corrective Actions is presented as a resource for the designer of an incident investigation system, with the assumption that the designer would make revisions in it to suit organizational needs. 

In Chapter 3, Serious Injury Prevention, an outline for such a study was presented under the heading Proposing a Study of Serious Injuries. Such a study will not be time-consuming since the data to be collected and analyzed should already exist or can be obtained easily. To assist in such a study, two addenda are provided at the conclusion of this chapter. Both are reprinted Ifom the third edition of On The Practice Of Safety Addendum A, A Systemic Causation Model for Hazards-Related Incidents, and Addendum B, Reference for Causal Factors and Corrective Actions. Another good reference when completing this evaluation, in terms of its comments on human errors that may be made above the worker level, is Chapter 4 here. 

A REFERENCE FOR THE SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS FOR INCIDENT INVESTIGATION PROCEDURES AND REPORTS... 

For most all reports, causal factors identified were plausible. Citing multiple causal factors was prevalent. References to written job procedures deriving from job hazard analyses or other job study methods were frequent. As in the original study, personnel who had participated in job hazard analyses had a better understanding of causal factors and did a more effective job of investigation. 

Once the causal factors have been identified, the factors are analyzed using a root cause analysis tool, such as 5-AVhys or predefined trees. See Chapter 9 for a more detailed discussion of Barrier Analysis (sometimes called hazard-barrier-target analysis or HBTA) and Change Analysis (also referred to as Change Evaluation/Analysis or CE/A). In essence, these tools act as a filter to limit the number of factors, which are subjected to further analysis to determine root causes. 

No formal assessment of the validity of each reference was undertaken in this process, although the levels of evidence afforded by different types of publications (i.e., case report vs. randomized, placebo-controlled double-blind study) were actively considered during the review process. In addition, it was observed that some identified publications were of limited value, especially those that lack sufficient detail about the specific herbal preparation addressed, and case reports that postulate a causal relationship between a specific herbal ingredient and a reported adverse effect, without consideration for confounding factors such as patient history or concomitant drug use. Some such references were nonetheless retained, though the editors attempted to call attention to their perceived flaws. 

This chapter briefly sets forth the fundamentals for incident investigation, makes reference to the previously mentioned Guide for Identifying Causal Factors Corrective Actions, and discusses incident costs. 

The basic concept from which event and causal factors charts were developed can probably be traced back to Ludwig Benner and others at the National Transportation Safety Board. Benner developed a very similar technique called multilinear event sequencing (MES) and more recently sequentially timed events plotting (STEP). Event and causal factors charts were part of the overall MORT approach to system safety developed by W. G. Johnson for the Atomic Energy Commission in the early 1970s and further developed and taught by the Department of Energy s System Safety Development Center (SSDC). The use of the event and causal factors chart is sometimes referred to as causal factors analysis. 

Reference is made several times in this book to an organization s safety culture and how it impacts on the injury experience attained, favorable or unfavorable. Since causal factors for incidents resulting in serious injury are largely systemic and their accumulation is a reflection of the organization s safety culture, that subject must be explored. Comments made on organizational culture in the August 2003 Report of the Columbia Accident Investigation Board on the Columbia space ship disaster are pertinent here. They follow. 

Several references were made in Chapter 3, Serious Injury Prevention, to human errors as the causal factors for accidents. And it was said that many serious injuries result from recurring but potentially avoidable human errors, and that organizational, cultural, technical, and management systems deficiencies often lead to those errors. Emphasizing human error reduction above the worker level, although proposed many years ago as a preventive measure, is not prominent in the work of safety professionals. 

As references are cited in this chapter, take note of those that have been published in recent years. Interest in human error reduction is warming up. The new literature relates to human errors as causal factors for injuries to employees injuries to users of personal products and damage to property and the environment. The amount of new literature indicates that human error reduction has acquired a new life. 

There are other references in the OECD report indicating that the effects of pressures to maintain high profit levels and reduce costs may be among the root causal factors for incidents that have low probability but serious consequences. In such cases, safety is compromised and the safety culture deteriorates. Although the OECD report pertains to the chemical process industries, similar observations may be made with respect to the negative impact of bottom-line pressures in other industries. 

For information about falls from stairs, probably the best reference is the Bureau of Labor Statistics Injuries Resulting from Falls on Stairs (Bulletin 2214). This particular booklet is excellent because not only does it provide statistical data but it is also an eye-opener for how these injuries occur. It is widely known and accepted, for example, that stairs are a high-risk area. It is also accepted that a loss of balance can occur from a slip or trip while a worker (or any person) is traveling up or down a stairway. Safety officials must consider why stairs are so hazardous. What are the causal factors ... 

Variations in the quality of causal factor determination were extreme. Of the 15 forms received, 10 direct the person who completes the form to identify the unsafe act of the employee. It is a prominent practice, whether intended or not, to put the principal responsibility for the incident on something the employee did or did not do. Unfortunately, it has been found that focusing on what the employee did or did not do—the unsafe acts—in determining casual factors is deeply embedded in the minds of many safety practitioners and the management personnel to whom they give advice. Some of the forms also asked that unsafe conditions be recorded. Sometimes, but seldom, they contain references to design and systems shortcomings. 

---