Event and Causal Factor analysis

Incident investigation requires identifying the preceding events and conditions, leading to the determination of

1.      Causes and

2.      Necessary and effective corrective and preventive actions.

These investigations need to probe the managerial systems and related latent factors that result in the events and conditions leading up to the incident to enable root cause determination.

Incidents hardly ever result from a single cause. Rather, they usually develop from a series of actions which include mistakes, changes, shortcuts, and omissions. Investigators need to also record the conditions affecting each event in the incident sequence.

The incident can be recorded visually as a flow of events leading up to the incident and beyond, if considered necessary. The use of branches or secondary chains may be useful.

Secondary event sequences, systemic factors and contributing factors are normally shown above or below the primary event sequence.

The following conventions are helpful to draw up an event and causal factor analysis diagram:

Events are shown by rectangles and events are connected by solid lines.

Conditions are shown by ovals and are connected to events or other conditions by dotted lines.

Events and conditions which have not been properly confirmed may be included in the diagram, but the rectangle and oval are then depicted with dotted lines.

The incident is often used as the starting point for the ECFA diagram, with events added in both directions to show what happened before and after the incident.

The purpose of the ECFA is as follows:

1. Clearly show the up-to-date investigation status.

2. Confirm what happened before, during and after the incident.

3. Identify findings, probable causes, and contributing factors.

4. Simplify the write up of the investigation report.

 Each event should

1.     Describe what happened with one subject and one active verb.

2.     Be quantified where possible, i.e., “the truck increased speed to 100km/hr."

3.     Be determined from the event and conditions preceding it.

 Conditions describe states or circumstances and are passive rather than active.

Conditions should be (as far as possible):

1.     Precisely described.

2.     Quantified.

3.     Posted with time and date.

4.     Derived directly from the conditions immediately preceding them.

 The following guidelines will help get the best results in doing an ECFA analysis:

 1.     Lay out the events and conditions identified as part of the incident using the formats proposed, as far as possible.

2.     Use the existing data to begin the ECFA as soon as possible, any gaps can be filled in at a later stage as the information becomes available.

3.     The use of post-it notes to create the ECFA has been widely recommended due to the ease of changing and re-arranging the ECFA.

4.     Decide on how detailed you need the ECFA to be.

5.     Create in addition an abbreviated executive chart which can assist in communicating the results of the investigation. 

Accurate ECFA analysis can reveal problems with systems that negatively impact production and business performance, by revealing the necessary cause-effect relationships and enabling corrective and preventive actions to be determined.

The ECFA can therefore achieve the following:

1.     Show all the cause-and-effect relationships that led up to the incident in the order that they happened.

2.     Make the investigation as transparent as possible through a kept-up to date layout.

3.     Assist in keeping the investigation as objective as possible.

4.     Show areas of responsibility.

5.     Clearly show the different root causes which will assist the process of determining preventive and corrective actions.

6.     Provide an aid which can be used for training for problem solving and on the job training.

High Level Example of ECFA