Causal factor analysis contributing causes

Each company s management style and safety systems have strengths and weaknesses. These strengths and weakness tend to influence the types and severity of incidents that might occur. An analysis of incident investigation findings in terms of causal factors, immediate causes, contributing causes,... 

Causal factor chain. This is a cause and effect sequence where a specific action creates a condition that contributes to or results in an event. This creates new conditions that, in turn, result in another event, etc. Figure 12-1 summarizes a root cause analysis flow chart [2]. 

The procedure relies on building a tree structure as shown in Figure 36-3. At the top is the principal or top undesired event. The tree continues by breaking the event into contributing factors and further subdividing them into event causes. Fault tree analysis is a deductive process that moves from the general to the specific. A tree chart considers the causal chain of factors leading to the top event. Interactions between events and elements of the system are a vital part of this method. 

The direct and indirect methods may be applied to single case studies as well as to frequent cases. The single case study of an accident is the method most frequently employed. The analysis of contributing factors follows a job-specific, implicit causal model. With respect to the frequency of their use factors are rank-ordered into behavior-related, technical, and organizational causes. Objectives are ... 

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