1. Procedures for Assessing Risks Chapter 13 – Event and Causal Factor Charting

2. CF = Causal Factor * = Item of Note CF CF Primary Event (Initiating Event) Primary Event Primary Event Primary Event Primary Event Accident Secondary Event Condition Secondary Event Secondary Event Secondary Event CF Condition CF Event * Condition CF SecondaryEventLinesPrimaryEventLineSecondaryEventLines Event and Causal Factor Charting

3. Limitations of Event and Causal Factor Charting Typically will not yield root causes Typically will not yield root causes Overkill for simple problems Overkill for simple problems

4. Procedure for Event and Causal Factor 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

5. Procedure for Event and Causal Factor 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

6. Tug or barge got under way Tug or barge approached the bridge Tug or barge struck ground Tank damage occurred Tug or barge off course Spill began Tug or barge Spill Tug or barge crew Marine patrol USCG Dept. of Env. Protection time Actor 1.0Gather and organize data

7. Procedure for Event and Causal Factor 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

8. 2.0 Select the accident Accident

9. Procedure for Event and Causal Factor 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

10. Accident Primary Event 3.0Define the primary sequence of events leading to the accident Condition

11. ActionCondition FactSupposition Verb (Past Tense) Active: walked, called, turned on, etc. Passive: was, were

12. Procedure for Event and Causal Factor 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

13. 4.0Complete the model by adding secondary events and conditions Accident Primary Event Secondary Condition Secondary Event Secondary Condition Condition

14. Procedure for Event and Causal Factor 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

15. 5.0Identify causal factors and items of note Accident Primary Event Secondary Condition Secondary Event Secondary Condition Condition Causal Factors