Root-Causes and Causal Factors: Effective Incident Investigation Closure

The ultimate goal of an incident investigation is to find the underlying reasons for the occurrence of the event in order to prevent its reoccurrence. These reasons can be divided in two categories: root-causes and causal factors. The root-causes usually have to do with management practices like: communication, training, and resource availability. The causal factors are usually related to physical and chemical phenomena, control system architecture, process design and procedural steps. Unfortunately incident investigation teams are usually trained to identify root-causes and don’t pay enough attention to the causal factors, leading to the generation of recommendations that sometimes take care of the symptom but don’t cure the disease. Not all the root-causes identified by the team are created equal; some of them are actual causes, some of them are just added to the list for ‘completeness’ and some of them are not relevant to the incident at all. Additionally in many investigations there is a rush to find these root-causes and establish corrective actions, this leads to a ‘checklist’ approach to incident investigation, where the team is given a sort of root-cause recipe/checklist.  This paper intends to show the importance of a detailed incident analysis that captures the causal factors as well as the root-causes and uses these findings to generate effective recommendations and lessons learned for the whole organization. This paper will present several cases of incident investigations where the root causes were partially identified without a complete understanding of the causal factors behind them, leading to waste of time and resources, additional near misses and repeated incidents with more severe consequences.