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ECFA Analysis

An ECFA [Events and Causal Factors Analysis] is a method of collecting data from accident and incident investigations, which is normally output as a chart to illustrate the events and Causal factors that would have been involved in an incident and how these interrelate. A simple ECFA Chart can be seen in the above example which involves a number of events and factors that have led up to a child being harmed. Systematic and Causal factors are referred to in ECFA as 'conditions' and are normally recorded above and below the relevant primary and secondary sequence of events. It is normally usual to differentiate between 'Systematic' and 'Causal' contributory factors as follows. Systematic is when the 'system' used is at fault resulting in reduced safety overall. For example, there is no formal safe system of working or safe working practices in place, risk assessments have not been undertaken for hazardous activities and staff are generally left to their own 'common sense' to 'get on with it' as part of the job. A 'Causal' factor is when failings take place due, in this case for example, advice been given on the use of physical force by someone not competent in their knowledge base in that area. This can be due to systematic failings where people in certain 'positions' are expected to advise without proper competent guidance or training, or where the person has decided to act outside of the scope of their employed role by advising on issues that they are not competent in but think that they know best. In the above example, which is based on an actual incident investigation where two care home staff were suspended for using force to prevent a child running into a busy road to try and commit suicide, we found, by asking some very simple questions, that the managers and the inspectors competence in the specific area in the use of physical force was subjective and not based on any competent understanding of the law, or indeed, the wider guidance available in there professional area of work.