Causal factor trees, example

An extension of the tree of causes, called variation diagrams (Leplat and Rasmussen, 1984) was developed to answer some of these criticisms. In this method, the Rasmussen stepladder model of human error (see Chapter 2) is applied to analyze causal factors at each node of the tree. A detailed example of the use of this technique is provided in Chapter 7 (Case Study 1). 

After the predefined tree has been used, a final generic cause test should be applied. The plant operating history, especially previous incidents, is considered to indicate if other generic management system problems exist. For example, repetitive failures may indicate generic causes that would not be apparent by only investigating the current incident. It is also an opportunity for a final overall review of the investigation to focus on the big picture, not just individual facts or causal factors. The team should ask, Are there any other causes that anyone has in mind that have not been included ... 

The following is an analysis of one of these causal factors contractor operator (CO) falls asleep. The basic technique works with any of the predefined trees commonly used within the process industry. However, for the purposes of this example, a proprietary tool C) has been selected, and therefore the structure of the tree and the terminology used is specific to that tree. 

Suppose that a causal factor chart is developed (see example in Fig. 1). However, there is no warranty, that each of the specific chains of underlying causes from the causal factor chart wiU be coimected to a corresponding generic chain of underlying causes from the predefined tree. Some of causal factors may have no root causes. 

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