Causal tree investigation tools

The earliest logic trees were based on engineering fault tree analysis methods. Today, companies use a number of variations or combinations of logic trees and call them by different names, such as Why Tree,< 9) Causal Tree,(20,21) Cause and Effect Logic Diagram (CELD),<22) and Multiple-Cause, Systems-Oriented Incident Investigation (MCS011).<23,24) tools have more similarities than differences. 

The committee s analysis was conducted on several levels. First, members investigated the causal factors for each of the seven events listed in Tables 2-1 and 2-2. They then developed a notional causal tree for each of the two events in Table 2-2 that were analyzed in depth. For illustrative purposes, a causal tree developed by the committee for the December 3-5,2000, incident at JACADS appears at Appendix F. The tree is a standard tool in reliability analysis and is particularly useful in human reliability analysis where operator actions contribute either positively or negatively to an incident. Lastly, the committee provides a series of general and specific observations about the events. 

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. 

While the use of predefined trees does not directly challenge the investigation team to think laterally of other possible causes, many predefined trees present a wide range of causal factors, some of which the team may not have otherwise considered. It is therefore possible, but unlikely, that the incident could involve a novel root cause that was not previously experienced by those who developed the predefined tree. The addition of a final test based on another tool, such as brainstorming, can overcome this apparent weakness. 

MORT is an analysis technique for identifying SR oversights, errors, and/or omissions that led to the occurrence of a mishap. MORT is primarily a reactive analysis tool for accident/mishap investigation, but it can also be used for the proactive evaluation and control of hazards. MORT analysis is used to trace out and identify all of the causal factors leading to a mishap or UE. MORT utilizes the logic tree structure and rules of FTA, with the incorporation of... 

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