Essential Factors™ is our investigation model for understanding and analysing an incident.
It is an ergonomic model and seeks to find those factors that were present in, or absent from, an incident sequence and were essential for the continuation of the sequence. Every essential factor provides for the investigator a potential point of control to prevent future incident sequences. This model was developed in the 1980s by Geoff McDonald.
Utilising the Essential Factors™ model in your organisation will allow investigators to identify a range of potential controls, other than the common administrative controls, that other investigation models may not produce. It provides you with an improved opportunity to prevent the recurrence of future incidents.
The Essential Factors™ model is not a cause-based model but a control-based model. Cause-based models seek to find ‘the cause’ or thing that triggered the incident sequence to exist. Often ‘the cause’ of the incident is regarded as an unsafe act or unsafe condition and the root or prime cause is regarded as something the organisation failed to do while planning and organising the work. Cause-based models are egocentric models in that they typically conclude that the cause was ‘human error’. This way of thinking often results in the addition of more administrative controls in an attempt to prevent humans making errors. Opportunities to do something better may have been missed.
A control-based model looks for the contribution of people, equipment and the working environment to the incident sequence. It is a balanced, objective model because it does not judge the contribution as safe or unsafe as this requires a value judgement which is not the basis of scientific analysis. Each contribution, if essential, then presents an opportunity for control. The model then assesses each contribution for how effectively it can be controlled. The aim is to optimise control not focus on cause. This model can initially appear counter-intuitive but is powerful and effective.
The Essential Factors model can be used as the basis for all your investigations or can be used to complement your existing analysis model.