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Causal Factors Analysis: An Approach for Organizational Learning

Causal Factors Analysis: An Approach for Organizational Learning
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In the companion textbook, High Reliability Operations: A Practical Guide to Avoid the System Accident (Hartley et al., 2008), we presented the concepts of high reliability operations and provided a practical approach to implementing those concepts using the Break-the-Chain Framework. The key to success of a high reliability organization (HRO) is the use of the Causal Factors Analysis (CFA) process to systematically evaluate where the organization came up short on its HRO practices.

A key component of being an effective HRO is being a learning organization and systematically adjusting procedures through system optimization and learning lessons from previous errors (HRO Practice 4). As noted in Chapter 6 of High Reliability Operations: A Practical Guide to Avoid the System Accident, the CFA investigative process provides an essential tool for organizational learning and event investigation. The CFA process enables an Investigation Team to focus in on those organization factors that are not aligned with the four HRO practices: 1) manage the system, not the parts; 2) reduce system variability; 3) foster a culture of reliability; and 4) learn and adapt as an organization.

We developed these four HRO practices to provide the major tenets of high reliability operations. These practices provide the desired end-state of the HRO from which we developed strategies, objectives, lines of inquiry, and metrics to measure progress towards the end-state of being an HRO, and to hopefully determine when the end-state is reached. We then developed the Break-the-Chain concept as a practical framework to help organizations implement the major HRO tenets. The Break-the-Chain Framework is used as a visual tool to understand how the four HRO practices would be implemented in everyday operations. The CFA process is the primary tool to evaluate the success of the organization in achieving the desired HRO end-state by comparing the pitfalls in the Break-the-Chain Framework to each of the four HRO practices. This will allow your organization to adjust its efforts to better achieve its desired HRO end-state.

Execution of the CFA process requires the investigators to work through the Break-the-Chain Framework in reverse, looking for failures that caused or contributed to the chain of events.

This text provides a guide to accomplish each step in the CFA process. The CFA process, and hence the selection of tools to perform the investigation, is designed to interrogate each of the potential failure modes of the Break-the-Chain Framework. This allows the organization to not only determine which HRP processes need Corrective Actions, but also provides feedback into the effectiveness of the HRO practices selected as important by the organization.


Business owners, corporations, organizations and their staff would be interested in using this method to improve their performance.

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