Causal factor identification barrier analysis

The process of evidence gathering, timeline development, scenario determination, and causal factor identification is somewhat iterative, and therefore some of the tools and quality tests previously described may assist in causal factor identification. More specifically, barrier analysis and change analysis, together with a completeness test, can ensure that all valid causal factors are identified. 

Causal factor identification is relatively easy to learn and apply to simple incidents. For more complex incidents with complicated timelines, one or more causal factors can easily be overlooked, however, which inevitably will result in failure to identify their root causes. There are a number of tools, such as Barrier Analysis, Change Analysis, and Fault Tree Analysis, that can assist with bridging gaps in data and the identification of causal factors. Each of these tools has merits that can assist the investigator in understanding what happened and how it happened. 

The design of most process plants relies on redundant safety features or layers of protection, such that multiple layers must fail before a serious incident occurs. Barrier analysis ) (also called Hazard-Barrier-Target Analysis, HBTA) can assist the identification of causal factors by identifying which safety feature(s) failed to function as desired and allowed the sequence of events to occur. These safety features or barriers are anything that is used to protect a system or person from a hazard including both physical and administrative layers of protection. The concepts of the hazard-barrier-target theory of incident causation are encompassed in this tool. (See Chapter 3.)... 

Rgure 2.68 shows a bow-tie analysis model (also referred to as X-tree analysis) of barriers. This analysis technique is a combination of FTA and ETA. The analysis begins with identification of the IE of concern in the center. An FTA is performed to identify the causal factors and probability of this event. Then an ETA is performed on all the barriers associated with the IE, and the possibilities of each barrier function failing. The various different failure combinations provide the various outcomes possible, along with the probability of each outcome. 

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