Causes causal/logic trees

In general, the companies surveyed use one of two main methodologies to determine root causes. The first involves timeline construction followed by logic tree development. The second involves timeline construction, identification of causal factors, followed by the use of predefined trees or checklists. These two approaches are discussed in detail in Chapter 9. 

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. 

Unlike the procedure followed in developing logic trees, the investigation team does not construct the tree. Rather they apply each causal factor to each branch of the predefined tree in turn, and those branches that are not relevant to the incident are discarded. This prescriptive approach offers consistency and repeatability by presenting different investigators with the same standard set of possible root causes for each incident. 

Causal Trees were developed in an effort to use the principles of deductive logic found in Fault Tree but make it more user-friendly. Originally, private companies developed the Causal Tree Method (CTM) for safety, process safety, and environmental incident investigations applications. Rhone-Poulenc, for example, was an early user.<20.21) Multiple-Cause Systems Oriented Incident Investigation (MCSOfl) is another name for the CTM. At this time, most companies use simplified versions of fault trees for complex incident investigations. 

For fault tree analysis, the starting point is to specify an undesirable serious situation, called the top effect, and then to consider all possible causes that could produce it. For example, the specified top effect could be the over-pressurization of a chemical reactor. Possible causes could include a reduction or loss of coolant, excess catalyst, an ineffective pressure control loop, etc. Each possible cause is analyzed further to determine why it occurred. For example, the pressure control loop problem could be to the result of a sensor or control valve malfunction. Thus, FTA is a top-down approach that generates a tree of causal relations, starting with the specified top event and working backward. Standard logic concepts, such as AND and OR, are used in the logic diagrams. 

Fault Tree Analysis employs an analytical tree to display the results of an analysis (Suokas and Rouhiainen, 1993). It starts with the top event (injury or damage). The analysis proceeds backwards in order to identify all events and conditions that have caused the injury or damage. Logical relations (necessary and/or sufficient conditions) are estabhshed. Fault-tree analysis is not an accident model per se and gives limited support in the identification of causal factors. 

---