Once the investigator has created a CF chart describing the event and filling in all the gaps possible, the next step in the SOURCE root cause analysis process is to determine the root cause(s) for each causal factor (or item of note) identified in the chart. Root causes are the most basic causes that can reasonably be identified, which management has control to fix and for which effective recommendations for preventing recurrence can be generated. Root cause identification is simply a process to help the investigator determine the underlying problems (i.e., root causes) associated with each causal factor. As defined earlier in this handbook, causal factors are human errors and equipment failures, which if eliminated, would have either prevented the event or reduced its severity. A causal factor, as identified in the CF chart, is a description of WHAT happened to cause the incident or HOW it happened. Before recommending workable preventive measures, the investigator must know WHY the causal factor occurred. Root cause identification helps the investigator examine, in a systematic way, possible reasons for the causal factor.