CAUSAL ANALYSIS

 Causal analysis is determining the most basic cause or causes of an incident.

 Purposes of Causal Analysis
 Ensure accurate reporting
 Learn from the incident
 Minimize possibility of recurrence
 Two major components that contribute to the cause of an accident / incident
1. surface cause- condition or act that directly caused the incident.
2. root cause is the system failure that allowed the surface cause to occur.
 Surface Cause- hazardous conditions and unsafe employee/manager behaviors and activities
that have directly caused or contributed in some way to the accident.
 Hazardous conditions:
 are basically things or objects that cause injury or illness
 may also be thought to be defects in a process
 may exist at any level of the organization
 Unsafe behaviors:
 are actions we take or don't take that increase risk of injury or illness.
 may also be thought to be errors in a process
 may occur at any level of the organization.
 The harmful transfer of energy is the direct cause of injury.
 Safety engineers closely analyze all the surface cause categories and attempt to (1) eliminate
the harmful energy, (2) reduce the harmful energy transfer, or (3) reduce exposure to harmful
energy transfer.
 Safety managers identify and analyze the safety management system to evaluate the
effectiveness of its subsystem components. They improve the system to eliminate or reduce
the common or root causes producing the hazardous conditions and behaviors.
 Root causes- underlying safety system weaknesses that have somehow contributed to the
existence of hazardous conditions and unsafe behaviors that represent surfaces causes of
accidents.
 Safety systems: Systems are developed to:
o Promote o Identify and control hazards
o Commitment/leadership o Investigate incidents/accidents
o Increase employee involvement o Educate and train
o Establish accountability o Evaluate the safety program
 System components:
o Policies o Procedures
o Programs o Budgets
o Plans o Reports
o Processes o Rules
 Three Levels of Cause Analysis
 Injury Analysis- we do not attempt to determine what caused the accident, but rather we
focus on trying to determine how harmful energy transfer caused the injury.
 Event Analysis (also called “special cause”)- we determine the surface cause(s) for the
accident: Those hazardous conditions and unsafe behaviors described throughout all
events that dynamically interact to produce the injury.
 Systems Analysis (also called “common cause”)- we're analyzing the root causes
contributing to the accident.
 The biggest challenge to effective accident investigation is to transition from event analysis
to systems analysis.
 Root Cause Analysis seeks to identify the origin of a problem. It uses a specific set of steps,
with associated tools, to find the primary cause of the problem, so that you can:
 Determine what happened
 Determine why it happened
 Figure out what to do to ensure it will not happen again
 Main Root Causes

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 Physical causes (Work Factors) - Tangible, material items failed in some way
 Human causes (Unsafe Acts) - People did something wrong. or did not doing something
that was needed.
 Organizational causes (Unsafe Conditions) - A system, process, or policy that people use
to make decisions or do their work is faulty
 How to Conduct a Root Cause Analysis
 Define the Problem
 Collect Data
 Identify Possible Causal Factors
 Identify the Root Cause(s)
 Recommend and Implement Solutions
 Root Cause Analysis Tools
 Five Whys Analysis
 Fault Tree Analysis
 Failure Mode and Effect Analysis
 Fishbone Method
 The 5 Whys- technique used in the Analyze phase of the Six Sigma DMAIC (Define, Measure,
Analyze, Improve, Control) methodology. It is a great Six Sigma tool that does not involve data
segmentation, hypothesis testing, regression or other advanced statistical tools, and in many
cases can be completed without a data collection plan.
 How to Complete the 5 Whys
 Write down the specific problem.
 Ask Why the problem happens.
 If the answer you just provided doesn’t identify the root cause of the problem that you
wrote down in Step 1, ask Why again and write that answer down.
 Loop back to step 3 until the team is in agreement that the problem’s root cause is
identified.
 Fault tree analysis (FTA) is a top down, deductive failure analysis in which an undesired state
of a system is analyzed using Boolean logic to combine a series of lower-level events.
 Graphic Symbols
 Event Symbols- used for primary events and intermediate events.
Symbol Use
Basic event failure or error in a system component or
element (example: switch stuck in open
position)
External event
normally expected to occur (not of itself a
fault)

Undeveloped event
an event about which insufficient information
is available, or which is of no consequence

Conditioning event
conditions that restrict or affect logic gates
(example: mode of operation in effect)

 Gate Symbols- describe the relationship between input and output events.
Symbol Use Formatted: Centered
OR Gate Formatted Table
- the output occurs if any input occurs
Formatted: Centered

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AND Gate -the output occurs only if all inputs occur Formatted: Centered
(inputs are independent)

Exclusive OR gate Formatted: Centered

- the output occurs if exactly one input
occurs

Priority AND gate - the output occurs if the inputs occur in a Formatted: Centered
specific sequence specified by a conditioning
event

 Transfer Symbols- used to connect the inputs and outputs of related fault trees, such as
the fault tree of a subsystem to its system. NASA prepared a complete document about
FTA through practical incidents.

 The failure mode and effects analysis (FMEA) is a technique aimed to find various modes for
failure within a system. Many manufacturing companies utilize this technique.
 FMEA requires several steps to execute:
 All failure modes (the way in which an observed failure occurs) must be determined.
 How many times does a cause of failure occur?
 What actions are implemented to prevent this cause from occurring again?
 Are the actions effective and efficient?
 The fishbone will help to visually display the many potential causes for a specific problem or
effect. It is particularly useful in a group setting and for situations in which little quantitative
data is available for analysis.

 Root Cause Analysis Tools

 Brainstorming
 Checklists
 Logic/Event Trees
 Timelines
 Sequence Diagrams
 Causal Factor Determination