Root cause analysis system generally

Tables 4.1 and 4.2 summarize the main types of studies of errors and adverse events, and their respective advantages and limitations. Thomas and Petersen s original source version has been separated into two separate tables and the content has been adjusted in particular, a section on case analysis has been added. Case analyses, usually referred to as root cause analysis or systems analysis, share some of the features of morbidity and mortality meetings, but are generally more focused and follow a particular method of analysis (Vincent, 2003) (Chapter 8).

The overall objective of the system is to map from three types of numeric input process data into, generally, one to three root causes out of the possible 300. The data available include numeric information from sensors, product-specific numeric information such as molecular weight and area under peak from gel permeation chromatography (GPC) analysis of the product, and additional information from the GPC in the form of variances in expected shapes of traces. The plant also uses univariate statistical methods for data analysis of numeric product information. 

Traditional accident models were devised to explain losses caused by failures of physical devices (chain or tree of failure events) in relatively simple systems. They are less useful for explaining accidents in software-intensive systems and for non-technical aspects of safety such as organizational culture and human decision-making. Creation of an infrastructure based on which safety analysis can function efficiently and effectively is needed. A so called safety culture for a development company and processes associated with routine tasks there, in general, is now identified as an area of root cause of accidents and that there is the greatest... 

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