Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation, Third Edition

Appendix A: Glossary

Terms relating to incident investigation are often used differently by different organizations and by personnel within an organization. Even investigators might use different terms. This glossary clarifies the meaning of these terms, which are listed alphabetically to help the reader search for terms within the list. Figure A.1 shows the interrelationship among some of the various terms defined here.


Figure A.1: Relationship Among Incident Investigation Terms

A

Accident
An incident with unexpected or undesirable consequences. The consequences can be related to personnel injury or fatality, property loss, environmental impact, business loss, harm to the company s reputation, or a combination of these.
Apparent Cause Analysis (ACA)
An analysis that identifies the causal factors for an incident and develops recommendations to address them, but does not necessarily identify the root causes of the incident.

C

Causal Factor
EPGs and FLPPGs that caused an incident, allowed an incident to occur, or allowed the consequences of the incident to be worse than they might have been.
  • Casual factors are gaps in the performance of equipment or front-line personnel. A performance gap is the difference between the desired performance of the equipment or human and the actual performance of the equipment or human.

  • For a typical incident, there are multiple causal factors. Causal factors are identified during the first stage of the analysis (see Section 4). Each causal factor is an event or condition that we want to eliminate. For each causal factor, underlying causes are identified and recommendations are developed.

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