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Procedures for Assessing Procedures for Assessing Risks Risks
Chapter 13 – Event and Chapter 13 – Event and Causal Factor ChartingCausal Factor Charting
CF = Causal FactorCF = Causal Factor* = Item of Note* = Item of Note
CFCF
CFCF
PrimaryEvent
(InitiatingEvent)
PrimaryEvent
PrimaryEvent
PrimaryEvent
PrimaryEvent Accident
SecondaryEvent
Condition
ConditionSecondary
Event
SecondaryEvent
SecondaryEvent
CFCF
Condition
CFCF Event
**
Condition
CFCF
SecondarySecondaryEventEventLinesLines
PrimaryPrimaryEventEventLineLine
SecondarySecondaryEventEventLinesLines
Event and Causal Factor Event and Causal Factor ChartingCharting
Limitations of Event and Causal Limitations of Event and Causal Factor ChartingFactor Charting
Typically will not yield root Typically will not yield root causescauses
Overkill for simple problemsOverkill for simple problems
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 4.0 Complete the model by adding secondary events
and conditions
5.0 5.0 Identify causal factors and items
of note
3.0 3.0 Define the primary sequence of events leading to the accident
2.0 2.0 Select the accident
1.0 1.0 Gather and organize data
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 4.0 Complete the model by adding secondary events
and conditions
5.0 5.0 Identify causal factors and items
of note
3.0 3.0 Define the primary sequence of events leading to the accident
2.0 2.0 Select the accident
1.0 1.0 Gather and organize data
Tug or barge Tug or barge got under got under
wayway
Tug or barge Tug or barge approached approached the bridgethe bridge
Tug or barge Tug or barge struck struck groundground
Tank Tank damage damage occurredoccurred
Tug or Tug or barge off barge off coursecourse
Spill beganSpill began
Tug or Tug or bargebarge
SpillSpill
Tug or Tug or barge crewbarge crew
Marine Marine patrolpatrol
USCGUSCG
Dept. of Dept. of Env. Env.
ProtectionProtection
timetime
•• •• •• •• • •
•• •• ••
•• •• ••
•• •• ••
••
•• • • •• • •
•• • • •• • •
•• • • •• • •
ActorActor
1.01.0 Gather and organize dataGather and organize data
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 4.0 Complete the model by adding secondary events
and conditions
5.0 5.0 Identify causal factors and items
of note
3.0 3.0 Define the primary sequence of events leading to the accident
2.0 Select the accident
1.0 Gather and organize data
2.02.0 Select the accident Select the accident
AccidentAccident
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 4.0 Complete the model by adding secondary events
and conditions
5.0 5.0 Identify causal factors and items
of note
3.0 Define the primary sequence of events leading to the accident
2.0 Select the accident
1.0 Gather and organize data
AccidentAccidentPrimaryPrimaryEventEvent
PrimaryPrimaryEventEvent
3.03.0 Define the primary sequence Define the primary sequence of events leading to the of events leading to the
accidentaccident
ConditionCondition
ActionAction ConditionCondition
FactFact
SuppositionSupposition
VerbVerb (Past Tense) (Past Tense)
Active: walked, Active: walked, called, called, turned on, turned on, etc.etc.
Passive: was, Passive: was, werewere
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 Complete the model by adding secondary events
and conditions
5.0 5.0 Identify causal factors and items
of note
3.0 Define the primary sequence of events leading to the accident
2.0 Select the accident
1.0 Gather and organize data
4.04.0 Complete the model by adding Complete the model by adding secondary events and secondary events and conditionsconditions
AccidentAccidentPrimaryPrimaryEventEvent
PrimaryPrimaryEventEvent
SecondarySecondaryConditionCondition
SecondarySecondaryEventEvent
SecondarySecondaryEventEvent
SecondarySecondaryConditionCondition
ConditionCondition
Procedure for Event and Causal Procedure for Event and Causal Factor ChartingFactor Charting
4.0 Complete the model by adding secondary events
and conditions
5.0 Identify causal factors and items
of note
3.0 Define the primary sequence of events leading to the accident
2.0 Select the accident
1.0 Gather and organize data
5.05.0 Identify causal factorsIdentify causal factorsand items of noteand items of note
AccidentAccidentPrimaryPrimaryEventEvent
PrimaryPrimaryEventEvent
SecondarySecondaryConditionCondition
SecondarySecondaryEventEvent
SecondarySecondaryEventEvent
SecondarySecondaryConditionCondition
ConditionCondition
Causal Factors
