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Three Insightful Methods for Causal Analysis

Causal-Analysis
Discover Accident Causes

In this post, we will look at Three Insightful Methods for Causal Analysis.  Only three?!  If you search online, you will probably find eight methods coming up:

  • Pareto Charts;
  • Failure Mode and Effect Analysis (FMEA);
  • Five Whys;
  • Ishikawa Fishbone Diagram;
  • Fault Tree Analysis;
  • 8D Report Template Checklist;
  • DMAIC Template; and
  • Scatter Diagrams.

However, not all these methods are created equal!  Only some provide real insight to the challenge of causal analysis.  So, I’ve picked the best ones – based on my 25 years’ experience in system safety – and put them in this post.

What are Causes and Why are They Important?

Before we go any further, I just want to explain some basic terms.  When we’re doing safety analysis we have hazards and as the sort of bow tie diagram suggests, one hazard can have many causes and one hazard can have many consequences.

The Accident Sequence Illustrated.

Now, some of those consequences will be harmless but some may result in harm to people. And that progression from causes to hazards to consequences is known as an accident sequence. We tend to Okay? So we’re looking at the worst-case scenario where somebody gets hurt.

(It’s not really the focus of this post, but the test for a hazard is it’s necessary for the accident. If there’s no hazard, there’s no accident. Once the hazard is present, nothing else weird or unusual needs to happen. For the accident to occur. So, the hazard is both necessary and sufficient.)

I’ve mentioned consequences, but today we’re talking about causes. So, we will analyze the left-hand side of the bow tie.

Three Insightful Causal Analysis Methods

Pareto Analysis

So, let’s start with a Pareto Analysis. I suspect most of us have seen this before. If we look at the causes of a certain outcome. What we often find is that a few causes are dominant.

An Example of a Pareto Chart.

In this chart, we’ve got types of medication errors.  In this case ‘a dose missed,’ ‘wrong time,’ ‘wrong drug,’ and then ‘overdose’ accounts for 70% of the causation.  Everything else is only 30%.

(Now, here they drew a line at 80% as the cutoff because sometimes Pareto is known as the eighty-twenty rule. And that’s suggesting that maybe 80% of the outcome is caused by 20 percent of the inputs or causes.  In other words, most of the output variable is driven by only 20% of the input variables.  That’s just a rule of thumb, and it doesn’t have to be 80/20, it might be 70/30, or 60/40, it doesn’t matter.)

The point is there are some dominant causes. If we can identify the dominant causes, and we work hard on just those top 2, 3, 4, or 5 causes, then we can get a disproportionate reduction in risk by concentrating on those few things.  Whereas, we could spend an awful lot of effort at attacking all the other causes and make very little difference.

It’s a simple technique, but by being led by the data we can become far more effective at risk management.

Failure Mode and Effect Analysis (FMEA)

FMEA is covered in another webinar. 

Ishikawa Diagrams

So an Ishikawa diagram or a fishbone diagram, as it’s often called for obvious reasons. Is a causal diagram (Image By FabianLange at de.wikipedia), and it’s often used.

Example of an Ishiawa, or Fishbone, Diagram Structured for Causal Analysis.

In accident investigations, the Ishikawa diagram becomes a vital tool. I recall learning its application through the tragic case of the Piper Alpha oil rig disaster. Despite the grim nature of such events, they demand thorough causal analysis. Whether we opt for predefined groupings like equipment, process, people, materials, environment, and management, or let the data guide us, the essence remains unchanged: we investigate accidents to identify potential outcomes or problems and determine their contributing factors.

What makes this method invaluable is its ability to transcend technical issues alone. By encouraging us to consider the broader socio-technical environment, it prompts a holistic view of complex systems. The diagram visually represents primary causes directly linked to the main ‘fishbone’ of analysis, while secondary causes may contribute to or stem from these primary factors. The potential for tertiary causes exists in theory, but it may complicate matters without appropriate tools.

Utilizing this technique for brainstorming is highly effective. Displaying it on a whiteboard and collectively contemplating it as a group fosters focused discussions. Subsequently, formal documentation in various formats ensures thorough record-keeping. This method proves particularly powerful for unraveling complexities within systems, a topic worthy of a dedicated webinar.

Fault Tree Analysis

Fault Tree Analysis is another widely used technique. We’ll have a webinar devoted to FTA later.

The Eight Disciplines Method

The Eight Disciplines method is one of those I often get mixed up with something else. It was introduced by the Ford Motor Co. (I’ve never used it) but it looks like a sensible method. There are actually nine steps:

  • Prepare and Plan
  • Form your Team
  • Identify the Problem
  • Develop an Interim Containment Plan
  • Verify Root Causes & Escape Points
  • Choose Permanent Corrective Actions
  • Implement Corrective Actions
  • Take Preventative Measures
  • Celebrate with Your Team!

Effective problem-solving requires careful planning, especially when it’s a team effort. Let’s break it down into three key steps:

  1. Immediate Action: Start by addressing the urgency. What can we do right now to contain the problem while we develop a more comprehensive solution? It’s crucial to manage the issue in the short term as we work on a more refined approach.
  2. Identify Root Causes: Investigate when and how the situation spiraled out of control. Pinpoint the opportunities for errors within the process. Understanding the root causes and timing issues is essential before moving forward.
  3. Implement Permanent Solutions: Now that we’ve dissected the problem, it’s time to implement long-term corrective actions. This involves establishing better control measures and preventive strategies to avoid similar issues in the future.

Finally, it’s important to celebrate with your team once the solution is in place. Whether it’s going out for a meal or another form of recognition, acknowledging the effort is crucial.

This structured approach acknowledges the multi-stage nature of problem-solving. It emphasizes the need for short-term fixes, data-driven decision-making for long-term solutions, and proactive measures to prevent recurrences. Even if you take away nothing else, remembering these key points can guide you through the process. For more detailed information, check out the provided link, and stay tuned for a downloadable PDF with additional resources.

Bonus – Cause Analysis Reports

And a little bonus here, something I picked up while looking through this stuff if you go to smartsheet.com, you’ll find a whole bunch of nice templates on course analysis reports. Okay? So I haven’t been through them all but there looks like quite a lot of good stuff in there if you’re interested.

We’ve created root cause analysis templates you can use to complete your own investigations. Whether you need root cause analysis Excel templates, a root cause analysis template for Word, or a PDF template, we have one that’s right for your organization.”

https://www.smartsheet.com/free-root-cause-analysis-templates-complete-collection

More Resources

Interested in accessing more content from the Safety Artisan? Head over to my Thinkific platform, where you’ll find my courses and all the webinars available at the academy. Plus, you can test it out with a 7-day free membership trial. For those looking for an extended trial, use the code ‘one-month-free‘ to enjoy a full month on us. I am continually updating our content, adding new material every month to keep things fresh.

Additionally, sign up for free email updates to stay informed about upcoming webinars and other exciting events.

Meet the Author

Learn safety engineering with me, an industry professional with 25 years of experience, I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.

Categories
Blog Tools & Techniques

Safety and Risk Audit

Safety and Risk Audit
Metrics by pexels-fauxels-3183153

So, what I’m talking about today is safety and risk audit, that is about process, Q&A, and some personal experience. Also something called layered process audits, which I ran into while researching this webinar. I thought that sounded interesting – and it is! Those are today’s topics for the webinar.

Audit Process

I’m talking about the safety audit process based on the UK Acquisition Safety and Environmental Management System or ASEMs. This was developed by experts for the UK MOD, and I remember it being introduced when I used to work there.

It’s a very good system, it’s very thorough and complete. (It is effectively copyright-free, so I can share it with you, and you can access, use it, and modify it perfectly legally.)

First, we should recognize the Project Oriented Safety Management System (POSMS). It is project-oriented. So the idea is we’ve got a program, or a project, where we’re buying something – a piece of equipment or a service. We’re contracting for something. It’s a project with a beginning, a middle, and an end.

In POSMS, they refer to auditing as a ‘system audit’…

Personal Experience of Audit

Now, I’ve mentioned some personal experiences so far. But I’ve got a few specifics that I want to bring to your attention. I’m doing so on the basis of 25 years in the business of being a safety engineer (see ‘Meet the Author‘, below).

So I will talk very briefly, about safety audit, what is it really? I mean, we talked about process, the mechanics of it, but what are we trying to achieve?

When and why do we use audits? What practices should we be following? And what should we not be doing? That last one is important because it’s easy to do it wrong. Who can be an auditor?

Also, there’s a brief word about the three different terms that get commonly confused. There are Independent Safety Auditors, Independent Safety Assessors, and Independent Safety Advisors. They are all ‘ISA’s and that sometimes gets confusing. What are the differences?…

Get the Webinar

See the whole webinar at the Safety Engineering Academy. (You can get discounts on membership by subscribing to my free emails.)

Course Curriculum

There are LOTS of goodies in this one.

  1. Videos & Slides:
  2. Safety Audit Templates:
    • aap01a-f-01 Audit Schedule
    • aap01a-f-02 Audit Details Team Composition and Competence Record
    • aap01a-g-01 Audit Competency Interim Guidance
    • aap01b-f-01 Audit Plan
    • aap01b-f-02 Audit Proforma
    • aap01c-f-01 Record of Audit Meeting
    • aap01d-f-01 Audit Report Template
    • aap02-f-01 Monitoring Schedule
    • aap02-f-02 Monitoring Data – Assessment Record
    • aap03-f-01 Management Review Form
    • aap04-f-01 Non-Conformance and Corrective Action Form
  3. )

There are five videos with an hour of content, (51 videos with 8.5 hours of webinar content in total). See it all at The Safety Engineering Academy here. More content is added every month.

Meet the Author

Learn safety engineering with me, an industry professional with 25 years of experience, I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.

Categories
Blog Safety Analysis Tools & Techniques

Five Ways to Identify Hazards

Hazard Identification
Hazard Identification

In my webinar ‘Five Ways to Identify Hazards’ I look at a mix of techniques. We need these diverse techniques to assure us (give justified confidence) that we have identified the full range of hazards associated with a system.

To do this I draw on my 25 years of experience (see ‘Meet the Author‘, below) and relevant standards. Here’s the introduction to the webinar.

Five Ways to Identify Hazards: Video Introduction

Webinar: ‘Five Ways to Identify Hazards’

Four Things to Remember

For hazard identification, we need to be aware of four things.

What we’re doing is we are imagining what could go wrong. And I want to emphasize, first of all, imagination. We need to be open to what could happen. That’s the mindset that we need, and we’re looking at what could go wrong, not what will go wrong. Think about possibilities, not certainties.

The second thing is that it’s very easy to dive down a rabbit hole and get into mega detail about one particular thing and spend lots of time, waste lots of time doing that. That’s not what we need to be doing. We need a broad approach. We need to go wide and think about as many different possible hazards as we can. Don’t dive deep that will come later, the deep analysis will come later.

Another aspect of that point is we’re talking about hazard identification. We’re just here to identify hazards. We’re not here to try to assess them yet.

Yet another mistake that people make is to try and jump straight to fixing the hazard. Many of us watching will be engineers. We love fixing problems. We like to solve problems, but we’re not here to solve the problem yet. We’re only here to identify it. So we’re going to avoid the temptation to jump in and try and come up with a solution. That’s not what we’re doing with hazard identification.

So those are four things to bear in mind.

Five Ways to Identify Hazards

Let’s move on. So I’ve said that this was entitled five ways to identify hazards.

There are, of course, many ways to identify hazards, but I just thought I’d pick on these five because there was a nice broad range of things and things that I can show you how to do straight away.

Those are the five things that we’ve got and we’ll have a slide on each one of those. First, we can ask the workers or end users or their representatives. Secondly, we can inspect the workplace, we can look around for hazards. And maybe we’ve got a real workplace that we can look at or maybe we’ve just got a representation, we can do both.

We can use a hazard identification checklist, we can survey historical data. So all the squiggly lines at the bottom of the screen, there’s an example of some historical data and we can conduct a number of analyses on that.

But the analysis I picked on (Number 5) is Functional Failure Analysis and we’ll see why in just a moment. So those are the five things that we will cover in the next hour. We’ll also have time for a Question and Answer session and then a worked example of how to do a simple Functional Failure Analysis…

There’s More!

This is just one of many webinars in my Safety Engineering Academy. You can see summaries of them all in this blog post.

Meet the Author

Learn safety engineering with me, an industry professional with 25 years of experience, I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.

Categories
Safety Analysis Tools & Techniques

Exploring Causal Analysis: Techniques and Insights

Example of Causal Analysis
A Fault Tree Analysis Cut Set

In this post, ‘Exploring Causal Analysis: Techniques and Insights’, I provide a quick summary of my recent webinar. You can see a short video introduction below, or access the full webinar at my Safety Engineering Academy.

Introduction:

Causal analysis is a vital aspect of system safety engineering, offering insights into the root causes of issues and guiding effective problem-solving strategies. In this webinar, we delve into various causal analysis techniques and discuss their practical applications in diverse domains.

Section 1: Introduction to Causal Analysis

Causal analysis involves understanding the sequence of events leading to an outcome and identifying the underlying factors contributing to it. We explore the fundamentals of causal analysis and its significance in safety engineering.

Section 2: Popular Causal Analysis Techniques

We examine eight popular causal analysis methods, including Pareto charts, Failure Mode and Effects Analysis (FMEA), 5 Whys, Ishikawa diagrams, Fault Tree Analysis (FTA), 8D reporting, DMAIC, and Scatter Diagrams. Each technique is analyzed for its strengths, limitations, and practical utility.

Section 3: Deeper Dive into Selected Techniques

We take a closer look at selected causal analysis techniques, exploring their application in real-world scenarios. Examples include using Pareto charts to identify dominant causes, leveraging FMEA for failure mode analysis, and utilizing Fault Tree Analysis for assessing complex system failures.

Section 4: Insights and Reflections

Drawing from years of experience in system safety engineering across diverse domains and international contexts, we share insights and reflections on the effectiveness of different causal analysis techniques. We emphasize the importance of choosing the right technique based on the specific objectives and available data.

Section 5: Resources and Next Steps

We provide attendees with valuable resources for further exploration of causal analysis techniques, including links to webinars, online courses, and templates. Additionally, we offer a glimpse into ongoing research and developments in the field of safety engineering.

Conclusion:

Causal analysis is a dynamic and evolving field that plays a crucial role in ensuring system reliability and safety. By employing a range of techniques and approaches, safety practitioners can gain deeper insights into the root causes of issues and implement effective risk management strategies.

Bonus: Q&A Sessions

Here are the two Q&A Sessions from the Webinar:

Causal Analysis – Q&A Session 1

Exploring Causal Analysis: Techniques and Insights – Get more here

Learn safety engineering with me, an industry professional with 25 years of experience, I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.

Categories
Blog Safety Management Tools & Techniques

Full Function Hazard Logs: A Deep Dive into Relational Databases

Computer Tracking Results
Photo by Lorenzo from Pexels

In this post ‘Full Function Hazard Logs: A Deep Dive into Relational Databases’, I explore some things we can do with a hazard log built upon a database.

In my 25-year career in safety engineering, I’ve seen many hazard logs and hazard tracking systems. Most of them were hosted in Microsoft Excel, but there were also commercial tools and bespoke databases. Let’s explore well beyond mere spreadsheets…

The Accident Sequence Illustrated.

In the realm of hazard management, navigating through the complexities of hazard logs, hazard tracking systems, and risk registers is crucial for ensuring safety and compliance. To shed light on this intricate process, we embark on a journey to explore the nuances of full-function hazard logs and their utilization within relational databases. Join us as we unravel the intricacies of hazard identification, risk assessment, and control measures within the realm of safety engineering.

Unveiling the Essence of Full Function Hazard Logs

Entities and Links in an Example Full-function Hazard Log

In our quest to decipher the essence of full-function hazard logs, we delve into the core components of relational databases. Our mission is clear: to unravel the labyrinth of entities within a hazard log, understand their interconnections, and discern the rationale behind data recording. By comprehending the diverse facets of hazard logs, we equip ourselves with the knowledge to tailor hazard log features to meet specific needs, ensuring efficiency and efficacy in hazard management processes.

Illustrating with Cassandra: A Glimpse into Hazard Log Tools

As we embark on this journey, we look closely at Cassandra, an exemplar of hazard log tools. While our focus remains steadfast on elucidating hazard management principles, Cassandra serves as a tangible illustration, offering a practical lens through which to explore complex concepts.

The Cassandra Hazard Log Logo
The Cassandra Hazard Log Logo

Through this illustrative example, we navigate the intricacies of accident causal control, dissecting the underlying hazard model that underpins our hazard management endeavors.

Deciphering Hazard Log Screens: A Comprehensive Overview

Venturing further into the realm of hazard log management, we dissect the various screens encapsulated within the hazard log interface.

A Screen with Accident-related Data and Links.

From the overview screen, where we gain a holistic view of accidents, hazards, causes, and controls, to the core screen, where we delve into the specifics of causal analysis, each screen offers a unique perspective on hazard management. By scrutinizing leading particulars, probability, severity, and post-control statuses, we unravel the intricacies of hazard identification and risk mitigation.

Unveiling the Power of Relational Databases

Central to our exploration is the underlying power of relational databases, where entities are intricately linked through many-to-many relationships. As we navigate through the database landscape, we witness the seamless integration of accidents, hazards, causes, and controls, each playing a pivotal role in shaping hazard management strategies. By harnessing the full potential of relational databases, we unlock a myriad of benefits, empowering us to make informed decisions and uphold safety standards with unwavering diligence.

Accessing Additional Resources: Empowering Your Hazard Management Journey

As we conclude our exploration of full-function hazard logs within relational databases, we extend an invitation to delve deeper into the realm of hazard management.

Through free email subscriptions and access to courses on safety engineering, we provide a gateway to further enrich your hazard management knowledge. Join our community of safety enthusiasts, engage in insightful discussions, and embark on a transformative journey toward bolstering safety practices within your organization.

Learn safety engineering with me, an industry professional with 25 years of experience, I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.

Categories
Blog Tools & Techniques

Safety Engineering Academy Webinars

Safety Engineering Academy
The Safety Engineering Academy on the Safety Artisan Thinkific Site

Safety Engineering Academy Webinars are on vital topics. I run them live every month, and you can get them all at the Safety Engineering Academy here.

They draw on my practical experience of these tools and techniques, from my 25-year-plus career. I have personally used all of these techniques, and I have seen them used on multiple programs in different industries and countries.

In these webinars, I provide not only theory but also pragmatic tips. I include the slides, as well as videos and sometimes templates and other aids. I hope that you find these packages helpful.

Next Webinar: HAZOP & SHARD

Welcome to my Webinar: HAZOP & SHARD! Join me online for an informative session on these crucial topics. I will delve into Hazard and Operability Studies (HAZOP) and Software Hazard Analysis and Resolution in Design (SHARD). Gain valuable insights and practical knowledge to enhance your understanding of these essential concepts. Don’t miss this opportunity to expand your expertise from the comfort of your own home. Register now to secure your spot!

There will be tickets for the webinar on Eventbrite.

The webinar will be at a NEW TIME of 15:30 p.m. (ACST) on Thursday, April 25th, 2024.

Webinar Series: Tools to Get the Job Done

A new series of webinars started in November. They will cover the most sought-after safety tools and techniques – and explain how to do them! Here they are:

  • HAZOP – Apr 24;
  • Event Trees – May 24;
  • Claim Argument Evidence & GSN – Jun 24; and
  • Fault Trees – Jul 24.

Previous Webinars

Past webinars are listed below. Again, they are always available in the Safety Engineering Academy on Thinkific.

Safety Audits

What is a Safety Audit?  When and why do you use them? Which practices are recommended or to be avoided? Who can be an auditor? Independent Safety Audit, Assessment, and Advice are commonly confused terms: what are the differences between them?  This webinar will cover all that – and more!

Safety Audit Process – Webinar Highlights

Causal Analysis

As well as answering FAQs, I will be talking about how we put causal analyses together. Webinar contents:

  • Cause Analysis:
    • Eight popular Tools/Techniques/Methods;
    • With (sometimes cynical) commentary; and
    • Resources.
  • Q&A Session; and
  • A Deeper Dive into Data for Causal Analysis.

Risk Registers & Hazard Logs

I’ve shared some content on this subject before (here and here), but in this webinar, I’m going to add to it substantially. As well as answering FAQs, I will be describing ‘full-function’ hazard logs, as provided by purpose-built databases (as opposed to mere Excel spreadsheets).

Risk Matrices

Highlights from the Risk Matrices Webinar

Learn how to use them properly! I covered a lot of content:

  • The most common questions;
  • What you do/don’t need a Risk Matrix for (and why); and
  • Problems with Risk Matrices and how to fix them!

Get the recordings here.

Failure Modes Effects Analysis

Get the free slides and FMEA template here.

Five Ways to Identify Hazards

Links to lesson discounts, and other resources:

  • The associated lesson (inc. this webinar & more) is here;
  • Free PHIA Guide here; and
  • Free email subscription with more discounts here.

Foundations of Safety Assessment

In this webinar ‘Foundations of Safety Assessment’, I look at Mil-Std-882E, Tasks 201, 202, and 203. The associated lesson (inc. this webinar & much more) is here.

Identify & Analyze Functional Hazards

In this webinar ‘Identify & Analyze Functional Hazards’, I look at Mil-Std-882E, Tasks 201 and 208. The associated lesson (inc. this webinar & much more) is here.

Workplace Hazard Analysis

Workplace Hazard Analysis (Mil-Std-882E, Tasks 206/207) Let’s look at How to implement common workplace Hazard Analysis Tasks.

System Safety in Systems Engineering

Hazard Analysis in Systems Engineering (Mil-Std-882E, Tasks 204, 205 & 209). How do we conduct Hazard Analysis in a Systems Engineering framework?

Meet the Author

My name’s Simon Di Nucci. I’m a practicing system safety engineer, and I have been, for the last 25 years; I’ve worked in all kinds of domains, aircraft, ships, submarines, sensors, and command and control systems, and some work on rail air traffic management systems, and lots of software safety. So, I’ve done a lot of different things!