BS en 62740. Root Cause Analysis (RCA) - (Draft)

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Title :
IEC 62740/Ed1: Root Cause Analysis (RCA)
Introductory note
ATTENTION
IEC CENELEC
PARALLEL VOTING
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62740/Ed1/CDV IEC(E)
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CONTENTS
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FOREWORD ........................................................................................................................... 4
Scope .............................................................................................................................. 7
Normative references ...................................................................................................... 7
Terms and definitions ...................................................................................................... 7
Introduction to RCA ......................................................................................................... 9
The RCA process .......................................................................................................... 10
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6.1
General ............................................................................................................ 16
6.2
Selection of analysis techniques ...................................................................... 17
6.3
Useful tools to assist RCA................................................................................ 17
Annex A (informative) Summary and criteria of commonly used RCA techniques ................. 19
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A.1
General ............................................................................................................ 19
A.2
RCA techniques ............................................................................................... 19
A.3
Criteria ............................................................................................................. 20
Annex B (Informative) RCA models ...................................................................................... 23
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B.1
General ............................................................................................................ 23
B.2
Barrier Analysis ............................................................................................... 23
B.3
Reasons Model (Swiss Cheese Model) ........................................................... 24
B.4
Systems models ............................................................................................... 25
B.5
Systems Theoretic Accident Model and Processes (STAMP) ........................... 25
Annex C (Informative) Detailed description of RCA techniques ............................................ 27
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5.1
5.2
5.3
5.4
Overview.......................................................................................................... 10
Initiation ........................................................................................................... 10
Establishing facts ............................................................................................. 12
Analysis ........................................................................................................... 13
5.4.1
Description ..................................................................................... 13
5.4.2
The analysis team .......................................................................... 14
5.5
Validation ......................................................................................................... 15
5.6
Presentation of results ..................................................................................... 16
Selection of techniques for analysing causes ................................................................. 16
C.1
C.2
C.3
General ............................................................................................................ 27
Events and Causal Factors (ECF) Charting ...................................................... 27
Multilinear Events Sequencing (MES) and Sequentially Timed Events
Plotting (STEP) ................................................................................................ 28
C.4
The Why method ............................................................................................ 31
C.5
Causes Tree Method (CTM) ............................................................................. 32
C.6
Why-Because Analysis (WBA) ......................................................................... 35
C.7
Fault Tree and Success Tree Method ............................................................... 38
C.8
Fishbone or Ishikawa Diagram ......................................................................... 40
C.9
Safety through Organisational Learning (SOL) ................................................. 42
C.10
Management Oversight and Risk Tree (MORT) ................................................ 43
C.11
AcciMaps ......................................................................................................... 45
C.12
Tripod Beta ...................................................................................................... 47
C.13
Casual Analysis using STAMP (CAST) ............................................................. 49
Annex D (Informative) Useful tools to assist RCA ................................................................ 53
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D.1
General ............................................................................................................ 53
D.2
Data mining and clustering techniques ............................................................. 53
Annex E (Informative) Analysis of human performance ........................................................ 55
E.1
E.2
E.3
General ............................................................................................................ 55
Technique for Retrospective and Predictive Analysis of Cognitive Errors
(TRACEr) ......................................................................................................... 56
Human Factors Analysis and Classification Scheme (HFACS) ......................... 58
55
Figure 1 RCA process ........................................................................................................ 10
56
Figure B.1 Broken, ineffective and missing barriers causing the focus event ...................... 23
57
Figure C.1 Example of an ECF chart .................................................................................. 27
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Figure C.2 Data in an event building block ......................................................................... 29
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Figure C.3 Example of a Time-Actor Matrix ........................................................................ 30
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Figure C.4 Example of a Why Tree .................................................................................... 31
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Figure C.5 Symbols and links used in CTM ........................................................................ 33
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Figure C.6 Example of a Cause Tree ................................................................................. 34
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Figure C.7 Example of a WBG ........................................................................................... 37
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Figure C.8 Example of a Fault Tree during the analysis ..................................................... 39
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Figure C.9 Example of a Fishbone diagram ........................................................................ 41
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Figure C.10 Example of a MORT diagram .......................................................................... 44
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Figure C.11 Example of an AcciMap .................................................................................. 46
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Figure C.12 Example of a Tripod Beta tree diagram ........................................................... 48
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Figure C.13 Control structure for the water supply in Walkerton, Canada. .......................... 50
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Figure C.14 Example CAST causal analysis for the local Department of Health ................. 50
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Figure C.15 Example CAST causal analysis for the local public utilit y operations
management ......................................................................................................................... 51
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Figure E.1 Example of an TRACEr Model [23] .................................................................... 56
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Figure E.2 Generation of Internal Error modes ................................................................... 57
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Figure E.3 Level 1 Unsafe Acts .......................................................................................... 59
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Figure E.4 Level 2 Preconditions ....................................................................................... 59
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Figure E.5 Level 3 Supervision Issues ............................................................................... 60
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Figure E.6 Level 4 Organisational Issues ........................................................................... 60
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Table 1 Steps to RCA ........................................................................................................ 10
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Table A.1 Brief description of RCA techniques ................................................................... 19
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Table A.2 Summary of RCA technique criteria.................................................................... 20
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Table A.3 Attributes of the generic RCA techniques ........................................................... 22
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Table B.1 Examples of barriers .......................................................................................... 24
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Table B.2 Example Barrier Analysis Worksheet .................................................................. 24
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Table C.1 Direct and indirect causal factors ....................................................................... 43
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Table E.1 External Error Modes ......................................................................................... 58
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Table E.2 Psychological Error Mechanisms ........................................................................ 58
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INTERNATIONAL ELECTROTECHNICAL COMMISSION
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____________
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ROOT CAUSE ANALYSIS (RCA)
FOREWORD
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1) The International Electrotechnical Commission (IEC) is a worldwide organization for standardization comprising
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International Standard IEC 62740 has been prepared by IEC technical committee 56:
Dependability.
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The text of this standard is based on the following documents:
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FDIS
Report on voting
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XX/XX/RVD
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Full information on the voting for the approval of this standard can be found in the report on
voting indicated in the above table.
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This publication has been drafted in accordance with the ISO/IEC D irectives, Part 2.
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The committee has decided that the contents of this publication will remain unchanged until
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related to the specific publication. At this date, th e publication will be
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replaced by a revised edition, or
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The National Committees are requested to note that for this publication the stability date
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THIS TEXT IS INCLUDED FOR THE INFORMATION OF THE NATIONAL COMMITTEES AND WILL BE
DELETED AT THE PUBLICATION STAGE .
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INTRODUCTION
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Root Cause Analysis (RCA) refers to any systematic process that identifies factors that
contributed to a particular event of interest (focus event). RCA aims to reveal root causes so
that either the likelihood of them occurring or their impact if they do occur can be changed.
RCA is performed with the understanding that events are addressed by understanding the
root causes, rather than the immediately obvious symptom s.
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RCA is used to analyse the root causes of focus events with both positive and negative
outcomes, but it is most commonly used for the analysis of failures and incidents. Causes for
such events can be varied in nature, including design, processes and techniques,
organisational characteristics, human aspects and external events. RCA can be used for
investigating the causes of non-conformances in quality (and other) management systems as
well as for failure analysis.
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An important distinction to make is that RCA is used to analyse a focus event that has
occurred and therefore analyses the past (a posteriori). However, knowledge of the root
causes of past events can lead to actions that generate improvements in the future.
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This standard is intended to reflect current good pract ices in the conduct of RCA. This
standard is general in nature, so that it may give guidance across many industries and
situations. There may be industry specific standards in existence that establish preferred
methodologies for particular applications. If these standards are in harmony with this
publication, the industry standards will generally be sufficient.
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This international standard is a generic standard and does not explicitly address safety or
accident investigation although the methods described in this standard may be used for this
purpose.
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ROOT CAUSE ANALYSIS
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Scope
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This International Standard describes the basic principles of Root Cause Analysis (RCA) and
specifies the steps that a process for RCA should include.
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This International Standard identifies a number of attributes for RCA techniques which assist
with the selection of an appropriate technique. It describes each RCA technique and its
relative strengths and weaknesses.
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RCA is used to analyse focus events that have occurred, therefore this International Standard
only covers a posteriori analyses. It is recognised that some of the RCA techniques with
adaptation could be used proactively in the design and development of items and for causal
analysis during risk assessment; however, this International Standard focuses on the analysis
of events which have occurred.
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The intent of this International Standard is to explain the techniques to identify root causes.
These techniques are not designed to assign responsibility or liability, which is outside the
scope of this International Standard.
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The following documents, in whole or in part, are normatively referenced in this document and
are indispensable for its application. For dated references, only the edition cited applies. For
undated references, the latest edition of the referenced document (including any
amendments) applies.
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IEC 60050-191, International Electrotechnical Vocabulary

Terminology
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For the purposes of this document, the definitions given in IEC 60050-191 and the following
apply.
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3.1
cause
set of circumstances that leads to failure or success
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Note 1 to entry:
maintenance.
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[SOURCE: IEC 60050-191, definition 191-43-11 modified to relate to failure or success]
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3.2
causal factor
condition, action, event or state that produced or contributed to the occurrence of the focus
event
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3.3
contributory factor
a causal factor regarded as secondary, according to an explicitly-given prioritisation of causal
factors
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3.4
direct cause
immediate cause where there is no other cause between the direct cause and the focus event
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Note 1 to entry: There may be more than one direct causal factor.
Normative references
Part 191: Dependability,
Terms and definitions
A cause may originate during specification, design, manufacture, installation, operation or
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3.5
event
occurrence or change of a particular set of circumstances
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Note 1 to entry: An event can be one or more occurrences, and can have several causes.
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[SOURCE: ISO Guide 73 2009 [1]]
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3.6
failure (of an item)
loss of ability to perform as required
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Note 1 to entry: When the loss of ability is caused by a pre-existing latent fault, the failure occurs when a particular
set of circumstances is encountered.
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[SOURCE: IEC 60050-191, definition 191-43-01]
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Note 5 to entry: This is failure of an item, not more generally of behaviour.
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3.7
failure mechanism
process that leads to failure
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Note 1 to entry: The process may be physical, chemical, logical, psychological or a combination thereof.
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[SOURCE: IEC 60050-191, definition 191-43-12 modified psychological added]
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3.8
focus event
event which the RCA is intended to explain causally
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3.9
necessary causal factor (of an event or state)
condition, action, event or state, that resulted in the given event or state, without which the
given event or state would not have occurred
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3.10
human error
discrepancy between the human action taken or omitted, and that intended or required
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Note 1 to entry: Ed.1 of IEC 60050-191 identified mistake as a synonym for human error, but a mistake is a type
of human error.
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3.11
item
subject being considered
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Note 1 to entry: The item may be an individual part, component, device, functional unit, equipment, subsystem, or
system.
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3.12
root cause
type of cause with no predecessor that is relevant for the purpose of the analysis
Note 2 to entry: An event can consist of something not happening.

Note 3 to entry: An event can sometimes be referred to as an incident or accident.
Note 2 to entry: A failure of an item is an event that results in a fault state of that item.
Note 3 to entry: Qualifiers, such as catastrophic, critical, major, minor, marginal and insignificant, may be used to
categorize failures according to the severity of consequences, the choice and definitions of severity criteria
depending upon the field of application.
Note 4 to entry: Qualifiers, such as misuse, mishandling and weakness, may be used to categorize failures
according to the cause of failure.
Note 2 to entry: The item may consist of hardware, software, people or any combination thereof.
Note 3 to entry: The item is often comprised of elements that may each be individually considered .
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Note 1 to entry: A focus event normally has more than one root cause .
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3.13
Root Cause Analysis
RCA
systematic process to identify the causes of a focus event
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Note 1 to entry: IEC 60050-191, definition 191-52-05 provides the following more restrictive definition systematic
process to identify the cause of a fault, failure or undesired event, so it can be removed by design, process or
procedure changes. This standard uses an extended definition to allow a wider applicability of the process.
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3.14
stakeholder
person or organisation that can affect, be affected by, or perceive themselves to be affected
by a decision or activity
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[SOURCE: IEC 60300-1, definition 3.1.17 [2]]
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3.15
stopping rule
a reasoned and explicit means of determining when a necessary causal f actor is defined as
being a root cause
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RCA refers to any systematic process that identifies the cause or causes that contribute to a
focus event. The immediate or obvious cause of a focus event is often a symptom of
underlying causes and may not truly identify the root cause or causes that should be identified
and addressed. RCA provides a greater understanding about why events have occurred. RCA
may identify the following:
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single root cause;
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multiple root causes in which the elimination of any cause will prevent the focus event
from occurring;
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root causes which are causal factors where elimination will change the likelihood of the
focus event occurring but may not directly prevent it;
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root causes of successes.
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By addressing the root cause or causes it is possible to make decisions regarding appropriate
actions that will generate better outcomes in the future; implementing appropriate actions
based on RCA are more effective at preventing the same or similar events with negative
outcomes occurring or increasing the probability of repeating events with positive outcomes,
when compared with just addressing the direct cause.
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RCA can be applied to any focus event whether success or failure, for example:
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investigation for technological, medical and occupational focus events;
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failure analysis of technological systems, to determine why an item failed to perform as

and when required;
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analysis of quality control and business processes;
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analysis of successful outcomes.
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RCA can be carried out at various levels of decomposition for example from system to
component level or by selecting different events or outcomes as a starting point. The level
appropriate to conduct the analysis will be dependent on the focus event.
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RCA is used to analyse focus events which have actually occurred and is therefore applicable
during the testing and operational phases of a project or product life cycle.
Note 2 to entry: In some languages the term root cause refers to t he combination of causes which have no causal
predecessor (a cut set of causes).
Introduction to RCA
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The benefits of performing RCA include:
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obtaining a greater understanding into what has happened;
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finding the source of problems so corrective action can prevent future events;
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identifying the causes of events with beneficial outcomes so they can be repeated;
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identifying more effective actions to address the causes of focus events;
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achieving the objectives of focus event inves tigations more effectively;
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supporting traceability between focus event investigation evidence and conclusions;
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increasing consistency between investigations of similar focus events;
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increasing objectivity of focus event analysis.
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The RCA process
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5.1
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To be effective RCA should be performed systematically as an investigation, with the root

causes and conclusions backed up by documented evidence. To achieve this, RCA should
include the five steps shown in Table 1 and illustrated in Figure 1.
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Table 1 Steps to RCA
Overview
Step
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Concepts and tasks to be performed
Initiation
Determine the need to carry out RCA and define the purpose and scope
Establishing Facts
Collect data and establish the facts of what happened, where, when and who
Analysis
Use RCA tools and techniques to ascertain how and why the focus event occurred
Validation
Distinguish and resolve the different possibilities as to how and why the focus event was
caused
Presentation of
Results
Present the results of the focus event analysis
RCA is iterative in nature especially the data collection and analysis , in that data is collected
on what happened, which is then analysed in order to determine what ot her data needs to be
collected. Once gathered, further analysis is conducted and any gaps identified, for which
further data is collected. This process is repeated until the purpose of the analysis is fulfilled
and the root causes identified. The outputs of the RCA will be dependent on the purpose and
scope.
Establish
the need,
purpose &
scope
What,
Where,
When &
Who
How and why

(identify
potential
causes)
Potential
causes
distinguished
and resolved
Outputs
Immediate
Facts
Data
Collection
Application of
specific tools
Further data
and testing
Step 1: Initiation
Step 2: Establishing Facts
Step 3: Analysis
Step 4: Validation
Step 5: Presentation
of Results
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Figure 1 RCA process
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5.2
Initiation
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346
The first step initiates the RCA process by evaluating the need to carry out RCA. It defines
the purpose and scope of the analysis, in response to the focus event, and establishes a team
and resources to carry out the RCA.
11
347
348
There is usually some criterion which is used to determine when an RCA is required, which
may include:
349
any single event with a large effect;
350
multiple similar undesirable events;
351
a parameter moving out of a defined tolerance level;
352
353
failures or successes (whatever the level of effect) that involve critical items of equipment
or activities.
354
355
356
357
358
359
360
When defining the type of events that require the conduct of RCA, it is important to consider
that an event with a large effect may have common root causes to events with minor effects.
Analysing and addressing root causes for events with minor effects may prevent a large effect
event occurring. Examples of events where RCA may be required include: completion of a
project (successes and failures), failures that result in unacceptable costs, injury or fatality,
unacceptable performance or delays, large contractual consequences, and equipment
breakdown.
361
362
363
364
365
366
If a RCA is required, the focus event(s) to be analysed is/are described and an appropriate
team appointed for the analysis. The description should include the background and context
in which the focus event(s) occurred. A good description of a focus event is short, simple, and
easy to understand and should not be biased towards a specific solution. This description is
used to identify appropriate members of the analysis team and ascertain where to start
collecting data.
367
368
369
370
The purpose and scope of the RCA should be determined taking into account knowledge of
system, functions, interfaces etc. In some cases the purpose of the analysis is to iden tify the
causes of the focus event, in others the purpose may be broader. For example, to also
identify matters of concern outside those that led to the focus event.
371
372
There are in general two different types of RCA that have different objectives and should not
be mixed up. These two types can be described as follows:
373
analysis of an observed focus event from other observed events;
374
analysis of an observed focus events from potential events, not actually observed.
375
376
377
378
379
The first version focuses on observed facts onl y. It may be an analysis "per se" according to
the purpose of the study and no hypothesis about event occurrence is acceptable for this
analysis. The second version focuses on potential (non -observed) events which may have led
to the actually observed focus event. It can be implemented when more facts are needed and
the use of hypothesis on the occurrence of events is acceptable for this analysis.
380
The outputs required of the RCA should also be identified, examples are as follows:
381
382
provide a description of each root cause along with sufficient background information to
allow the identification of suitable actions;
383
384
recommend actions that, taken together, prevent further occurrences of similar events with
adverse consequences and improve the likelihood of succes ses;
385
identify, implement and review actions to address root causes.
386
387
388
389
RCA can include the analysis of open systems ( systems which continuously interact with their
environment); this interaction can take the form of information, energy, or material transfer .
Therefore, the scope should specify the boundary of the analysis (what is included and what
is excluded).
390
391
392
393
The scope of the analysis should where possible include a definition of the stopping rule ,
which is the point at which action can be defined or additional proof of cause is no longer
necessary for the purpose of the analysis. For example the last point where corrective action
can be identified, before factors that cannot be influ enced e.g. weather. It may however be
12
394
395
more appropriate to ascertain the stopping rule at review points that determine whether
further analysis is required.
396
397
The team members for the analysis should be selected based on the specific expertise
needed to analyse the focus event. The team should include:
398
399
a person or persons who between them can provide a complete systems overview and
knowledge of the programme or project and focus event;
400
401
a facilitator skilled in the causal analysis technique, desirably trained or experienced in the
facilitation of the causal analysis technique;
402
at least one member experienced in the causal analysis technique being applied.
403
404
405
406
407
408
409
410
411
412
413
Team members can change depending on the activity being conducted e.g. team members
responsible for data collection will not necessarily be the same as those conducting the
analysis. Team members can include engineers, technicians, operators, sales
representatives, managers etc. The use of external parties should be considered to provide
an independent perspective and avoid blind spots that may exist in the organisation.
Additional team members should be included for specific activities during the investigation to
either bring expertise into the team or to increase the influence of the team. The role of these
additional team members is to support the investigation so that it is not h alted for technical or
organisational boundary reasons. It is not appropriate for persons who may have had a role in
causation of the focus event to be part of the team. Their input should be collected during the
first two steps.
414
415
416
417
RCA can be effectively carried out by one person provided that person is experienced with the
causal analysis technique, is a domain expert (or has immediate access to domain experts)
and has access to all the data required. However, it is more common to conduct RCA as a
team.
418
5.3
419
420
421
This step includes all the activities necessary to prepare for the analysis. Establishing the
facts is usually the largest part of the RCA. Facts should be determined on what happened,
where, when and by whom.
422
423
Data should be collected, before it is lost (e.g. before evidence is disturbed or removed, or
memories fade). Data should aim to identify:
424
the context in which the focus event occurred;
425
the conditions before, during, and after the focus event;
426
personnel involvement including actions taken (or not taken) and decisions made;
427
context data about the surroundings, including environmental data ;
428
429
how the organisation operates including organisation charts, processes and procedures,
training and skills data;
430
historical data relating to similar events or precursors;
431
deviations from the expected;
432
interactions with other items and personnel;
433
equipment involved and its operating state .
434
The following lists examples of data that may be relevant.
435
436
437
Inspection of physical evidence such as failed components and failure reports. Generally,
it is experience that will determine what physical evidence is required. If there is doubt,
the evidence should be retained, it is also important to preserve the evidence.
438
439
Photographs and videos taken by monitorin g cameras. Photographing the area of the
occurrence from several views will also be useful in the analysis phase.
Establishing facts
13
440
441
442
443
Operational data, recorded by monitoring systems, control systems, alarm and event
loggers etc. Operator logs can be critical to understanding the operating conditions at the
time of failure and since they are typically dated, they are ideal for generating a timeline of
events.
444
445
446
447
448
449
450
Personal testimony gathered by conducting interviews. Interviews should concentrate on

data collection e.g. building a consistent timeline etc; any premature discussion of the
causes of the failure may adversely impact the interview process. Questions should
be prepared before the interview to ensure that all necessary information is obtained.
Interviews should be conducted with those people, who are most familiar with the focus
event, however, consider interviewing other personnel e.g. people who have performed
the job in the past. All interviews should be documented.
451
452
Documentary evidence of relevant procedures, o perating environment and regulatory

environment.
453
454
455
456
Once all the data associated with the focus event has been collected, the data should be
reviewed for correctness and suitability, missing data should be obtained and any
inconsistencies should be resolved to ensure a clear and consistent picture of the focus event
is determined.
457
458
459
This step can include failure analysis which examines failed components using a wide array of
methods including microscopy, spectroscopy and Non-Destructive Testing or models on the
development of failure such as fire modelling or crash modelling.
460
461
The outcome of this step is information and understanding, supported by physical evidence
and witness statements, concerning:
462
what happened including the circumstances that lead to the focus event;
463
the time sequence of events which lead to the focus event;
464
the location of the focus event;
465
actions of people associated with the focus event;
466
any necessary conditions for the focus event;
467
the consequences of the focus event.
468
5.4
469
5.4.1
470
471
472
473
Having determined what happened, where, when and by whom, this step establishes
how and why the focus event occurred. The objective of this step is to understand the focus
event and its causes by structuring the data that has been collected into a form that allows
root causes to be systematically derived.
474
475
476
477
478
RCA normally analyses facts to identify the causal factors that were necessary for the focus
event to occur. However in some cases, for example where sufficient facts are not available,
the analysis may propose one or more hypotheses for cause and may also identify
contributing factors and prevailing conditions which were possibly associated with the focus
event, but cannot be proven to be necessary causes.
479
Analysis involves the following.
480
481
Organising the physical evidence and witness statements concerning actions, events,
conditions and outcomes.
482
483
484
Seeking how and why the focus event occurred using the data collected to justify
conclusions. Models of causation, laboratory testing, check lists and taxonomies or
statistical analysis of data may be used to assist this process.
485
486
Looking beyond direct causes to why those causes occurred. The aim is to seek all factors
(and conditions) that contributed, not only the immediate or obvious causes.
Analysis
Description
14
487
488
489
490
491
492
In general causes may involve technical issues, human aspects and factors relating to the
physical or psycho-social environment in which the focus event occurred. All of these should
be considered in seeking root causes. People with expertise in these areas should therefore
be involved in the analysis.
493
494
495
Causes should be described clearly and unambiguously. Where a human action, omission or
decision is identified as a cause, the nature of the act or decision should be specified e.g. the
operator switched off the wrong power switch and not the human error.
496
The analysis of cause (depending on the purpose and scope of the analysis) can consider:
497
498
how the focus event occurred i.e. the physical chemical psychological or logical process
that was involved;
499
preceding events or conditions that were necessary to the focus event occurring;
500
501
relationships between causal factors including how they combined to cause the focus
event and how a root cause leads to the focus event;
502
503
organisational and management influences and human factors that were involved in the
focus event or in the events and conditions leading up to it;
504
505
prevailing conditions that may have contributed to the event occurring but were not
necessary causes;
506
507
matters of concern that could lead to other focus events (these are not strictly causes but
may be an outcome of the analysis).
508
509
510
511
512
513
514
515
A structured analysis technique should be used to perform the analysis. S everal formal
techniques exist ranging from those that are based on a checklist of causes to techniques that
guide the analyst through consideration of causes and graphically present the results. The
techniques range from simple to complex and require suitably skilled practitioners or
facilitators to conduct the analysis. Some techniques are based on particular models of how a
focus event occurs and hence give a particular emphasis to the results. The different models
are based on different hypotheses with regard to the causation therefore they tend to lead the
investigator to identify different contributory factors.
516
517
In some cases it is appropriate to use more than one technique or take into account
considerations of more than one model to identify all root causes.
518
519
520
Models of causation are described in Annex B and a nalysis techniques are described in
Annex C. The most appropriate technique will be dependent on the focus event and the
purpose and scope of the analysis (see clause 6).
521
522
523
The analysis may indicate that further data is required. Requests for such data should be
expected to occur throughout the analysis to resolve inconsistencies or complete gaps in the
analysis. The analysis should continue until a stopp ing rule is invoked.
524
5.4.2
525
526
A leader should be appointed for the analysis step, who is responsible for the following
preparatory work.
527
528
Obtaining copies of the agreed role and responsibilities of the team, and purpose and
scope of the analysis.
529
Obtaining copies of the focus event description and the facts established.
530
Deciding the analysis technique(s) to be used.
531
532
Converting the focus event description and facts established into a suitable format for use
in the analysis technique selected.
533
Developing an analysis plan.
Continuing this process until the stopping rule is invoked and root causes identified. There
may be multiple root causes which can be independent or inter related.
The analysis team
15
534
Forming the analysis team.
535
Facilitating or arranging for training of team members in the analysis technique selected.
536
Selecting software tools or other templates for use during the analysis .
537
538
539
Arranging for a search to be made of databases, media, legal proceedings etc. to identify
focus events of a similar nature, or which may have occurred with the same or similar
technologies.
540
541
542
543
544
The leader should review the information available to determine what analysis technique(s)
should be applied and what skills are required. Expert advice in the field of RCA may need to
be obtained regarding the selection of the analysis technique. The leader may also require an
expert RCA facilitator for all or part of the analysis, depending on the complexity o f the focus
event, the complexity or volume of evidence and data or analysis technique selected.
545
546
547
548
549
550
The analysis is usually carried out by a team, with each team member being chosen for their
experience and skills. The analysis team should be as small as pos sible, consistent with the
relevant technical and operating skills and experience being available. Where input will be
required from multiple parties, stakeholders or entities, the analysis team should contain
representatives of each. It is the leaders responsibility to ensure the relevant stakeholders are
informed, so that adequate stakeholder representation is available during the analysis.
551
552
553
554
The role and responsibilities of the analysis team members should be determined and
milestones established at the outset of the analysis. A programme of meetings should be
developed, which reflects the objectives and milestones provided to the analysis team. This
will ultimately enable any recommendations to be carried out in a timely fashion.
555
The leader should develop an analysis plan, which should contain the following:
556
focus event description;
557
agreed roles and responsibilities of the team, and the purpose and scope of the analysis;
558
a list of team members and the stakeholders to be represented;
559
time, date and location of the analysis meetings;
560
a summary of the data available;
561
analysis technique(s) to be used;
562
563
arrangements for training the analysis team in the selected analysis technique (if
required);
564
565
the form of recording of the analysis and the analysis results, inclu ding reference to any
templates or software tools to be used.
566
567
568
569
570
571
572
Adequate room facilities with visual and recording aids should be arranged by the leader for
the efficient conduct of the analysis meetings. A briefing package consisting of the analysis
plan and any essential pre-meeting reading or references should be sent to the analysis team
members in advance of the first meeting, to allow them to familiarise themselves with the
information available and the selected analysis technique. At the first analysis meeting a
physical review of the focus event via a re-enactment, mock-up, computer simulation or scale
model is desirable.
573
574
575
The leader should ensure that an appropriate communication system is in place for informing
and transferring the results of the anal ysis to those responsible for the next step of the RCA
process (see 5.5).
576
5.5
577
578
579
580
A number of review activities are conducted throughout the RCA process to determine
whether data collected is relevant and the analysis is representative of the data colle cted.
This step tests whether the causes identified in the analysis can be substantiated and may be
interleaved with the analysis or conducted as a separate activity .
Validation
16
581
582
583
584
585
586
587
An independent review can be carried out to assess whether the analysis is complete and
correct and to determine whether the purpose of the analysis has been fulfilled. The review
method will be dependent on the analysis technique used and on the focus event. In some
cases experiments can be performed to repeat the occurrence of the focus event, where
appropriate statistical methods should be used to assess the degree of confirmation of the
hypothesis of cause. If the causes are validated with the help of simulation, care should be
taken to ensure that the simulation is true in the casually-relevant respects.
588
589
590
During the analysis there may be several alternative hypothesis of how the event could have
happened, at the completion of the analysis the causes should be validated and only a single
hypothesis should remain.
591
592
This step may require further data collection to seek direct evidence to support or refute the
causes identified. Evidence may not always be available to fully validate all potential causes.
593
5.6
594
595
596
597
598
599
600
The results of the analysis will depend on the purpose of the analysis. For example, if the
purpose of the analysis is to identify actions that, taken together, prevent further occurrences
of similar events, the analysis results should identify corrective actions which break the causal
network and prevent the focus event occurring again. If the purpose of the analysis is to
repeat successes, then actions that enhance the likelihood or the consequences of the focus
event should be proposed. The effectiveness of the analysis results is dependent on the
quality of the analysis.
601
602
603
604
An agreed format for presenting the results of the RCA should be developed that summarises
the analysis and captures the required outcomes from the analysis e.g. recommended
actions. If recommended actions are the required outcome from the RCA, t he summary should
include the following as a minimum:
605
606
607
608
a general description of each cause and contributory environmental conditions requiring

action along with sufficient background information and detail to allow those who will make
recommendations and implement them to be able to understand the need to address each
cause and justify actions to be taken;
609
610
a set of options for treatment actions, and where practicable and within scope a summary
of the benefits and costs of each;
611
recommended actions to address each of the causes identified.
612
613
Recommended corrective actions should be evaluated for effectiveness and realism. In

general corrective actions aim to achieve the following:
614
615
616
change the likelihood of the focus event and/or its consequences (i.e. reduce the
likelihood or consequence of undesirable events or increase the likelihood or consequence
of successful events);
617
618
not introduce new unacceptable risks e.g. the safety of other systems must not be
degraded by the proposed corrective action.
619
620
621
622
623
Where actions are identified they should be reviewed prior to implementation to determine
whether they have not only addressed the root causes, but also not introduced new
unexpected consequences and will therefore function as intended. Also reoccurrence of the
same or similar event should be monitored. If an unexpected occurrence reoccurs, the original
focus event should be re-evaluated to determine why actions were not effective.
624
625
6.1
626
627
Formal techniques have been devised to help analysts identify causes and eventually root
causes. Analysis techniques may perform one or more of the following functions:
628
629
Presentation of results
Selection of techniques for analysing causes

General
organise data and provide structure to the analysis and identify where further evidence is
needed;
17
630
631
provide a visual display of the evidence relating to the focus event for example the time
sequence of events or causal chains;
632
633
conduct statistical analysis of the data, particularly from multiple similar events, to identify
common causes;
634
635
provide guidance to identify possible causes for further investigation and comparison with
data (such methods include check lists and methods based on models of causation );
636
guide the analysts through multiple levels of cause to a set of root causes.
637
6.2
638
639
640
RCA is undertaken in varying degrees of depth and may use one or several analysis
techniques ranging from simple to complex. The depth of the analysis and technique(s) used
should exhibit the following characteristics:
641
642
be justifiable and appropriate to the focus event under analysis and the scope and
purpose of the analysis;
643
provide results that enhance the understanding of the root causes of the focus event;
644
be capable of use in a manner that is traceable, repeatable and verifiable.
645
The analysis techniques to be used are selected based on the applicable factors such as:
646
characteristics of the analysis technique;
647
characteristics of the focus event e.g. severity or potential severity or complexity;
648
649
characteristics of the organisation e.g. industry/sector ap proved techniques or cost benefit

evaluation;
650
purpose of the analysis e.g. outputs required or stakeholder expectations ;
651
the causation model or models most appropriate to the objectives of the analysis .
652
653
The attributes of the most commonly used analysis techniques are described at Annex A. The
criteria used to characterise the techniques, described in Annex A, are as follows:
654
expertise required;
655
tool support;
656
scalability;
657
graphical representation;
658
modularity;
659
reproducibility;
660
plausibility checks;
661
intellectual rigour;
662
time sequence;
663
specificity.
664
665
The analysis techniques are described in Annex C, which includes the methods and process
used for each technique along with their strengths and weaknesses.
666
6.3
667
668
669
670
671
Modern data mining techniques enable a search for specific properties and conditions.
Clustering analysis selects data that are closely related, and thereby identify deviating data
(outliers). Modern cluster analysis can detect data that are closely related in one, two or more
dimensions and thereby analyse products or processes that are closely related and identify
deviating data points (outliers). An overview of these techniques is provided in Annex D.
Selection of analysis techniques
Useful tools to assist RCA
18
672
673
674
Many focus events and analysis techniques involve human factors and several taxonomies
have been developed to assist in finding root causes where human behaviour is involved. Two
examples are given in Annex E.
19
Annex A
(informative)
675
676
677
678
Summary and criteria of commonly used RCA techniques
679
A.1
General
680
681
682
This Annex lists the most commonly used RCA techniques, with a brief description, and
provides a reference list of criteria which can be used to compare different RCA techniques.
The list is not comprehensive but covers examples of the different types of techniques used.
683
A.2
684
Table A.1 provides a list and brief description of the most commonly used RCA techniques.
RCA techniques
Table A.1 Brief description of RCA techniques
685
Technique
Description
Events and Causal Factors

(ECF) Charting
ECF analysis identifies the time sequence of a series of tasks and/or actions and the
surrounding conditions leading to a focus event. These are displayed in a cause effects diagram.
Multilinear Events
Sequencing (MES) and
Sequentially Timed Events
Plotting (STEP)
MES and STEP are methods of data-gathering and tracking for the anal ysis of
complex focus events. The results are displayed as a Time-Actor Matrix of events.
The Why Method
The Why Method is a simple series of questions that guides the analysis to the root
causes.
Causes Tree Method

(CTM)
CTM is a systematic technique for analysing and graphically depicting the events
and conditions that contributed to a focus event. CTM is similar to the why method in
concept but builds a more complex tree and explicitly considers technical,
organisational, human and environmental causes.
Why-Because Analysis
(WBA)
WBA establishes the network of causal factors responsible for a focus event using a
two-factor comparison, the Counterfactual Test. The network of factors is displayed
in a Why-Because Graph.
Fault Tree and Success

Tree Method
Fault or Success Tree is a graphic display of information to aid the user in

conducting a deductive analysis to determine critical paths to success or failure,
which are displayed graphically in a logic tree diagram.
Fishbone or Ishikawa
Diagram
The Fishbone or Ishikawa Diagram is a technique that helps identify, analyse and
present the possible causes of a focus event. The technique illustrates the
relationship between the focus event and all the factors that may influence it.
Safety through
Organisational Learning
(SOL)
SOL is a checklist-driven analysis tool, oriented towards focus events in nuclear

power stations. Results in the visual form of a Time -Actor Diagram, derived from the
MES/STEP method.
Management Oversight
and Risk Tree (MORT)
The MORT chart is a pre-populated fault tree with events, usually faults or
oversights, expressed in generic terms. The MORT tree contains two main branches
and many sub-branches giving a high level of detail. One main branch identifies
about 130 specific control factors while the other main branch identifies over 100
management system factors. The chart also contains a further 30 information system
factors common to both main branches of the tree.
AcciMaps
AcciMaps is primarily a technique for displaying the results of a causal analysis. It

requires an organisational model to separate factors into layers and to elicit factors
in the layers; applies a version of the Counterfactual Test (see WBA) to determine
the causal relations amongst the factors.
Tripod
Tripod is a tree diagram representation of the causal network, focusing on human

factors and looking for failures in the organisation that can cause human errors.
Causal Analysis for

Systems Theoretic
Accident Model and
Process (STAMP) (CAST)
CAST is a technique that examines the entire socio-technical process involved in a

focus event. CAST documents the dynamic process leading to the focus event
including the socio-technical control structure as well as the constraints that were
violated at each level of the control structure.
20
686
A.3
Criteria
687
688
689
Table A.2 provides a list and describes the criteria used to characterise the RCA techniques
listed in Table A.1. Each criterion has three levels indicated by a (+), (o) or a (-), where the
different levels indicate the range.
690
The attributes for each RCA technique using the criteria in Table A.2 are shown in Table A.3.
691
Table A.2 Summary of RCA technique criteria

Criteria
Expertise
required
Tool Support
Scalability
Graphical
Representation
Description
Is the method targeted towards the "sophisticated
user" (does it require use of techniques such as
theorem proving which requires specific
expertise)? Is it suitable for use by domain
experts only?
Is tool support necessary?
Is the method scalable? Can the method be used

cost-effectively for simple as well as complex
focus events? Can a subset of the method be
applied to small, or to less-significant focus
events and the full capability applied to large, or
to significant focus events? So the question of
scalability asks whether the complexity of analysis
using the method scales with the complexity of the
focus event.
What is the nature of the method's graphical
representation?
The motivating principle is that a picture is better
than a thousand words. It is often more
comprehensible to display results of an analysis
method as an image, a graph, or other form of
illustration, than as purely written text.
Levels
Intuitive, little training necessary (+).
Limited training required e.g. one

day (o).
Considerable training effort

necessary, e.g. one week (-).
Can be well applied without

dedicated tool support, e.g. Office
type tools (+).
Tool support not required but usually

needed for effective application (o).
Tool support necessary, can be

applied only with dedicated tools
support (-).
Scales well with complexity (+).
Limited scalability, considerable

overhead with every application (o).
Not scalable, the full method has to

be applied (-).
Graphical representation with clearly

defined semantics and cognitively
easy to understand (+).
Graphical representation, but without

semantics (o).
No graphical representation defined

(-).
The results can be reproduced,

differences are only observed on the
representation of the results,
wording etc. (+).
A significant amount of the results

can be reproduced, but some
differences will be observed (o).
The results will depend on the

analyst and their expertise (-).
The desirable properties of a graphical

representation are:
Reproducibility
to display clearly the semantics of causality

(including denotation of causal factors, and
taxonomic classification of factors);
to be cognitively (relatively) easily evaluated

by a single person;
ideally, a graphical representation could also

display the history of the analysis.
Are the results of the method reproducible? Would

different analysts obtain similar results for the
same focus event?
21
Criteria
Plausibility
Checks
Intellectual
Rigour
Description
Are there reasonable, quick plausibility checks on
the results obtained which are independent of the
tool? What ways are there of checking the
"correctness" of the results? One example would
be checklists.
How rigorous is the method? Rigor has two

relevant aspects:
Time Sequence
Specificity
692
Does the method have a rigorous meaning,

formal semantics, for the key notions of
cause, causal factor and root cause? Is the
semantics easy to apply?
Levels
There are plausibility checks for

almost all aspects (+).
There are plausibility checks, e.g.

checklists, but they do not
necessarily cover all aspects (o).
There exist only limited means

supporting plausibility checks (-).
Formally defined and can be formally

verified (+).
Semi-formal definition (o).
Informal definition (-).
Yes (+).
Only indirectly (o).
No (-).
Method analyses specific necessary

causes of the focus event (+).
Method can be used to analyse

generic problems as well as the
necessary causes of the focus event
(o).
Method seeks problems in general

whether or not they were necessary
causes of the focus event (-).
Are the results of the method amenable to

formal (mathematical) verification? To what
extent is an application of the method so
amenable?
Does the method contain a representation of time

sequence of events?
The extent to which the method limits analysis to

necessary causal factors of the focus event rather
than exploring a range of general problems with
the system that existed at the time of the focus
event and may have contributed.
22
Table A.3 Attributes of the generic RCA techniques
693
Expertise
Required
Tool
Support
Scalability
Graphical
Representation
Reproducibility
Plausibility
checks
Intellectual
Rigour
Time
Sequence
Specificity
ECF
MES and
STEP
The Why
Method
CTM
WBA
Fault Tree
and Success
Tree Method
Fishbone or
Ishikawa
Diagram
SOL
MORT
AcciMaps
Tripod Beta
CAST
The criteria for each attribute is described in Table A.2.
694
23
Annex B
(Informative)
695
696
697
698
RCA models
699
B.1
General
700
701
702
703
704
705
This Annex describes the most commonly used RCA models which provide different ways of
thinking about focus events. The different models are based on certain hypothesis with regard
to the focus event e.g. Barrier Analysis assumes the focus event has occurred as a result of
missing, defective or ineffective barriers. Therefore, the different models tend to lead the
investigator to identify different causal factors. Models are used to direct thinking in
conjunction with the techniques of Annex C, or simply to identify a set of causes.
706
B.2
707
B.2.1
708
709
710
711
Barrier analysis is based on the hypothesis that a focus event occurs as a result of the
interaction of a source of harm on a target and that this can be prevented by the use of
barriers [3]. An undesirable event occurs when the barriers are missing, defective or
ineffective (see Figure B.1).
Barrier Analysis
Overview
Target
Source of harm
712
Failed
barrier
Missing
barrier
Failed
barrier
Ineffective
barrier
Missing
barrier
713
Figure B.1 Broken, ineffective and missing barriers causing the focus event
714
715
716
717
718
719
720
Haddon [3] considered focus events where the source of harm is physical energy and barriers
relate to how the energy can be modified or prevented from impinging on the target. The
model has been extended in various ways [4], for example barriers are often divided into
physical barriers and administrative barriers (see Table B.1 for some examples). Barriers may
also be considered in terms of prevention, protection and detection (for example in the
context where the focus event is a fire these would be using non -flammable materials,
providing fire extinguishers and installing smoke alarms).
721
722
723
The output of the analysis generally includes a Barrier Analysis Worksheet (see Table B.2),
which identifies those barriers that either were available but ineffective or were not in place
during the occurrence of the focus event.
724
24
Table B.1 Examples of barriers
725
Physical or Energy Barriers
Administrative Barriers
Engineered safety features
Plant operating and maintenance
Safety and relief devices
Regulations, Policies and practices
procedures
Conservative design allowances
Training and education
Redundant equipment
Work protection
Locked doors and valves
Work permits
Ground fault protection devices
Skilled people
Shielding and guards
Methods of communication (3-way communication)
Alarms
Supervisory practices
Automatic fire containment systems
Table B.2 Example Barrier Analysis Worksheet
726
UNDESRIED OUTCOME
(WHAT HAPPENED?)
SOURCE OF
HARM
(List one at a time,

need not be in
sequential order.)
Maintenance worker
loosened nuts on
flange of the pipe line
that was pressurized
Pressurised
liquid
BARRIER(S) THAT
SHOULD HAVE
PRECLUDED THE
UNDESIRED EVENT
(List all physical and
administrative barriers
for each undesired
outcome)
BARRIER
FAILURE
MECHANISM
Procedure to switch off

pump and release
pressure before
commencing work
Pressure
released on
wrong system
(HOW THE
BARRIER
FAILED)
BARRIER
ASSESSMENT
(WHY THE
BARRIER(S) FAILED)
(Identify if the barrier
was missing, weak, or
ineffective; and why.)
Unclear labelling
727
B.2.2
Strengths and limitations
728
The strengths of Barrier Analysis are as follows:
729
730
731
The limitations of Barrier Analysis are as follows:
732
733
may not recognise all failed or missing barriers, or th e effect of the rate of frequency with
which the barriers are challenged;
734
735
addresses direct causes rather than root causes i.e . it seeks what barrier failed and how,
but does not explore why in any depth.
736
B.3
737
B.3.1
738
739
Reasons model [5] is based on the premise that the basic required elements of any
productive system are:
740
appropriate decisions from plant and corporate management;
741
line management activities, operations-maintenance training etc;
742
reliable and fit for use equipment;
743
motivated workforce;
744
integration of human and mechanical elements;
745
safeguards against foreseeable risks.
746
747
748
There are inevitably weaknesses in these elements that can be considered to be latent
failures. If these come together a triggering event, which m ay be unimportant in other
circumstances, results in failure.
identifies what corrective actions are required to ensure adequate barriers (number and
effectiveness) are in place.
Reasons Model (Swiss Cheese Model)

Overview
25
749
750
751
752
The weaknesses in the elements of the productive system are pictured as holes in slices of
Swiss cheese. An event will result when all individual weaknesses align. Reasons model is
not strictly a barrier model as the layers are normal operating systems with weaknesses
rather than failed barriers or controls.
753
754
Human error Taxonomies based on Reasons model have been developed for a number of
different industries.
755
B.3.2
756
The strengths of Reasons Model are as follows:
757
758
759
The limitations of Reasons Model are as follows:
760
761
superficial analysis of technical or environmental causes which c onsiders technical

aspects only in terms of failed barriers;
762
763
assumes the core problem is operator error (errors at other levels and organisational
failures are explored primarily in terms of how they influence operator error );
764
765
766
does not supply a taxonomy to assist with the identification of motivations and
psychological precursors of human error or in identification of latent failures and hence
requires expertise in individual and organisational psychology to use properly.
767
B.4
768
769
770
Systems theory [6] was developed in the 1940s and 1950s to handle the increase in
complexity of systems after WWII and to consider the social and technical aspects of systems
together as a whole.
771
772
773
774
775
776
777
In system models it is assumed that human interaction with technology in complex social
structures is influenced by the organisations goals, policy and culture and by internal and
external economic, legal, political and environmental elements. This system is stressed by the
fast pace of technological change, by an increasingly aggre ssive, competitive environment,
and by factors such as changing regulatory practices and public pressure. In this context
focus events are due to multiple factors and are typically waiting for release and not due to
any one act or event.
778
779
780
781
782
783
Failures arise due to the complex interactions between system components that may lead to
degradation of system performance. Two or more discrete events within system elements can
interact in unexpected ways which designers could not predict and operators cannot
comprehend or control without exhaustive modelling or test. Factors contributing to the focus
event may include effects of decisions which are normal in the circumstances in which they
were made but produce an unwanted outcome.
784
785
786
787
Methods based on a systems model do not seek a causal chain or look for individual error or
technical failures but consider the system as a whole, its interactions and its weaknesses.
Individual human or hardware failures may be recognised but the focus is on interactions and
systemic issues.
788
B.5
789
B.5.1
790
791
792
793
794
795
STAMP [7] is a causality model based on systems theory [6] that extends the traditional
model (chains of directly related failure events) to include both the technical and social
contributors to focus events and their relationships. It also captures focus event s involving
interactions among non-failing system components and processes, indirect and systemic
causal mechanisms, complex operator and managerial decision making, advanced technolog y
such as digital systems and software, and system design flaws.
796
encourages the analyst to explore causes of operator error and hence possible means of
reducing it.
Systems models
Systems Theoretic Accident Model and Processes (STAMP)

Overview
26
797
798
799
800
801
802
803
804
805
806
STAMP assumes incidents arise in interactions among humans, machines, and the
environment and treats systems as dynamic control problems in which the controls aim to
manage the interactions among the system components and its environment. The goal of the
control is to enforce constraints on the behaviour of the system components, for example,
aircraft in an air traffic control system must always maintain a minimum separation distance.
Focus events result from inadequate control or enforcement of constraints on the
development, design, and operation of the system. In the Challenger loss, for example, the O rings did not control propellant gas release through the fi eld joint of the Space Shuttle. In
STAMP, the cause of a focus event is a flawed control structure.
807
808
809
STAMP also incorporates the concept that incidents often arise from a slow migration of the
whole system toward a state of high risk [8] so that financial and other pressures that lead to
changing behaviour over time can be accounted for in the causal analysis process.
810
B.5.2
811
The strengths of STAMP are as follows:
812
considers the role of the entire socio-technical system in causation;
813
includes indirect and systemic factors in the causal explanation;
814
provides a model to explain accidents in very complex systems;
815
identifies causes back to the process with which a system was developed.
816
The limitations of STAMP are as follows:
817
818
819
820
requires focus events to be analysed in a way that is often unfamiliar to engineers,

therefore may take more time to learn how to analyse focus events using causal analysis
processes based on STAMP.
27
Annex C
(Informative)
821
822
823
824
Detailed description of RCA techniques
825
C.1
General
826
827
828
829
This Annex describes a range of techniques used during a RCA. The list is not comprehensive
but covers examples of the different types of techniques used. Many of these techniques are
supported by software tools. Some of the methodologys and software tools have elements
that are proprietary, which may impact on the cost of implementing the technique .
830
831
832
833
834
835
836
Some techniques aim to identify causes that can be shown to be necessary if the focus event
is to occur. Other methods seek general weaknesses of the system as a whole that probably
contributed to the focus event but where the focus event could have occurred in their
absence. In some terminologies a cause cannot be so described unless it is necessary to
the focus event. In this Annex such causes are referred to as necessary caus al factors.
Identified weaknesses that may have played a part in the focus event but may not be
necessary to it are referred to as contributory factors.
837
838
839
In general identification of necessary causal factors will be repeatable and based on

evidence. There may be a higher level of subjectivity in identifying contribut ory factors and
different analysis techniques with a different focus may identify different factors.
840
C.2
841
C.2.1
842
843
844
845
846
847
848
849
The ECF chart [9] records events in chronological order from left to right in rectangles, with
events characterised by single subjects and active verbs. Each event is derived strictly from
the one before. Conditions necessary for the events are displayed in ovals above and below
the sequence of events. (Conditions are states or circumstances rather than happenings).
Events are connected by solid lines and conditions by dashed lines. Events and conditions
based on evidence have a solid outline, whereas those that are presumptive have a dashed
outline. There may be multiple or branching sequences of events each with their own
conditions.
850
851
852
Figure C.1 illustrates an example of an ECF chart, in which a maintenance activity was
incorrectly carried out due to the maintainer turning up late, resulting in an emergency landing
carried out by an aircraft.
Events and Causal Factors (ECF) Charting

Overview
853
Maintainer
turns up late
for work
Flight
scheduled for
09:00
Crew decide
to start flight
prep
Outdoor ambient temperature

15 degrees C
Flight delayed
awaiting
inspection
Aircraft rolled
out of hanger
for flight prep
Inspection equipment does not

reach ambient temperature
09:15 01/10/12
09:20 01/10/12
Maintainer
receives
tasking
Maintainer
collects
required
equipment
09:05 01/10/12
No other
maintainers
available
Maintainer
ignors
requirement
for hangar
inspection
Maintainer
carries out
inspection
task on
engine
Aircraft
declared
serviceable
Engine fails
Aircraft
carries out an
emergency
landing
09:50 01/10/12
10:30 01/10/12
13:00 01/10/12
13:20 01/10/12
Equipment storage
ambient temperature
25 degrees C
854
855
Figure C.1 Example of an ECF chart
28
856
C.2.2
Process
857
The following describes the process for developing an ECF chart.
858
1) Identify the focus event and record it in a box on the right hand side.
859
860
861
862
863
2) Record the primary chain of events that led to the focus event where each event in the
chain is both immediate and necessary to the event on the right hand side. Therefore, the
consequence is recorded on the right hand side of each event (cause). Also, the
consequence of a previous event may be at the same time a cause of following event. The
events are displayed in rectangles linked by arrows to the right of the focus event.
864
865
3) Determine what conditions led to these events. State each of them in an oval above the
relevant event.
866
867
4) Add any secondary chains of events that may be relevant to the focus event and their
conditions.
868
869
5) Check the validity of the causes by obtaining evidence that determines whether the
conditions and events are true.
870
871
6) Develop the ECF chart until the event at the start of the sequence is identified and all
conditions which can be verified by evidence are added.
872
873
874
875
Generally the exact chronology of events is not known at the beginning of the investigation
and becomes clearer as the investigation proceeds. A method should therefore be used that
allows investigators to easily change the sequence of events and conditions as more
information is gained.
876
C.2.3
877
The strengths of ECF are as follows:
878
assists the verification of causal chains and event sequences;
879
provides a structure for collecting, organising, and integrating evidence;
880
identifies information gaps;
881
882
assists communication by providing an effective visual aid that summarises key

information regarding the focus event and its causes.
883
The limitations of ECF are as follows:
884
identifies some causes but may not necessarily determine the roo t causes;
885
it can be overcomplicated for simple problems.
886
887
C.3
888
C.3.1
889
890
MES [10] and STEP [11] are methods developed to analyse focus events in complex systems,
where STEP is a successor to MES.
891
892
893
894
As with ECF charting, MES/STEP conceives a focus event as arising from an interlinked
succession of events with events characterised by a single subject and an active verb. In
MES and STEP the subject is called an actor (which may be human or machine, or even a
property).
895
896
897
898
Events are represented as event building blocks (BBs), which consist of (partial or full) data
records as described in Figure C.2. These are arranged during the analysis in a Time-Actor
Matrix where the vertical axis of the matrix represents the different actors, and the horizontal
axis represents time.
899
The Time-Actor Matrix also contains:
900
Strengths and Limitations
Multilinear Events Sequencing (MES) and Sequentially Timed Events

Plotting (STEP)
Overview
conditions necessary for enabling an event along with precursor events;
29
901
902
903
904
An example showing part of the representation of a tank maintenance eve nt is given in Figure
C.3.
annotations for further tasks in an investigation, such as a note indicating a deficit of

information, or an incomplete explanation of an event.
DATE SOURCE
STANDARDIZED MES BUILDING BLOCK ELEMENTS
WITNESS REPORTS
ATTRIBUTE CHANGES
INSTRUMENT RECORDS
TESTS
RESIDUES
MOVEMENTS
OBSERVATIONS
STATEMENTS
DECISIONS
INSTRUCTIONS
INJURIES
DEBRIS
OTHER
ACTOR
ACTION
OBJECT/DESCRIPTOR
LOCATION
REMARKS
SOURCE
Person, object or energy that did something

What Actor did
Additional data defining action
Location where action began
For remarks about BB or investigation
Source of data used in BB creation
BEGIN DATE/TIME
DURATION
END DATE/TIME
LINKS FROM/TO
N/S STATUS
Date and time action began

Duration of action
Date and time action ended
Links defining interactions among BBs
Necessary/sufficient input validation status
905
Figure C.2 Data in an event building block
906
907
C.3.2
Process
908
MES/STEP has the following steps.
909
910
1) Gather information for the initial series of building blocks, and identify and track missing
information.
911
2) Arrange the initial building blocks in an initial Time -Actor Matrix.
912
913
3) Specific techniques are then used to identify and generate hypotheses to fill the gaps
with events (in the form of further building blocks).
914
915
4) The process terminates when an analyst considers that sufficient information is available
in the Time-Actor Matrix.
916
C.3.3
917
918
919
920
921
922
923
MES/STEP has the same strengths and limitations as ECF. Data formatting is relatively more
elaborate, and there are explicit mechanisms for determining and tracking missing data and
attempts to determine those data. Some such bookkeeping mechanisms are necessary for
managing complex investigations with multiple investigators. The Time -Actor Matrix also has
explicit notation for recording the state of an on-going inquiry along with data-acquisition and
explanatory tasks yet to be performed. This means that a comprehensible visual
representation of the state of an investigation is available at all points in an investigation.
30
Reported BB
Hypothesized BB
Inferred BB
Temporary BB
Required BB
Questionable BB
Incomplete BB
Disputed BB
Actors
Event Building Blocks
Internal
Internal pressure
overstressed
Internal pressure blew

tank cover upward and
to the north
Report A Page Y
Report A Page Z
Pressure
Maintenance
Technician
Maintenance
Technician
signed equipment
isolation record
Maintenance
Technician
proceeded to location A
Maintenance
Technician
positioned at location A
Maintenance
Technician
removed bolts to tank
cover with tool C
Isolation Record
Report A Page X
Inferred from scenario
Report A Page Y
Operator A
accompanied
maintainer to assist
with task
Operator A positioned
at location B
Report A Page X
Inferred from injury
Operator A
Why did the operator

place himself at risk?
05:30:00
924
925
05:30:30
05:35:00
05:37:00
Time
Figure C.3 Example of a Time-Actor Matrix
05:37:30
31
The Why method
926
C.4
927
C.4.1
928
The Why Method uses a straightforward questioning process to arrive at the root causes.
929
930
931
932
Questioning starts with a statement of the situation and ask s why it occurred. The answer to
this question is turned into a second why question and the answer to this into a third question.
Questioning ceases when the stopping rule is reached. Generally this requires approximately
5 levels of questions hence the method is sometimes known as 5 whys.
933
934
Where a why question provides several causes each is explored and the method produces a
Why Tree.
935
936
937
938
The why method is used alone for simple situations but is also inherent in more complex tree
methods such as the Causes Tree Method (CTM) (see C.5). It can be useful for eliciting
information from witnesses on how and why an event occurred because the simple question
why does not make assumptions about cause or lead the witness.
939
940
941
942
943
944
Figure C.4 illustrates an example of a compressor that has experienced an unscheduled

shutdown. In the example the fourth why suggested a number of potential causes for lack of
lubrication and evidence was sought to define which in fact occurred. Although a human error
was involved in that a person did not follow specified start up procedures, t he
recommendation is to improve the design so the compressor and pump motors are linked.
Further analysis of why the error occurred, in this case, is not useful.
Overview
945
Figure C.4 Example of a Why Tree
946
947
C.4.2
Process
948
The Why Method has the following steps.
949
1) Identify and record the focus event as the start of a Why diagram .
32
950
2) Ask why the focus event occurred, seeking only the direct causes.
951
952
3) Ask why successively with respect to the previous answer. In each case the answer to
the question why should be an immediate ca use of the previous answer.
953
954
955
956
957
The question why is asked as many times as is needed to lead to a root cause, which is
normally five questions but this is only a guideline. Each time the question is asked, there
may be multiple answers and some analysis wil l be needed to eliminate those possible
answers that are not applicable. It may be more effective to ask why did the process fail?
instead of just asking why.
958
959
960
It can be useful to consider a set of categories of cause such as from the Ishakawa method
and to involve a team of people. This will help ensure that all relevant areas are considered
by the investigators.
961
C.4.3
962
The strengths of the Why Method are as follows:
963
simple to apply by those involved in the problem;
964
easy to understand by others;
965
quick process to achieve results for simple problems;
966
does not require extensive knowledge from the person asking the questions;
967
968
does not require a lot of training or extensive knowledge from the person asking the
questions.
969
The limitations of the Why Method are as follows:
970
only suitable for simple situations;
971
972
973
heavily dependent on the knowledge and expertise of the people answering the questions,
with expertise in both technical failure modes and human error often required to reach the
root causes;
974
root causes are likely to be missed if outside the k nowledge base of those involved;
975
possible uncertainty about when the appropriate root ca uses have been identified;
976
977
can be developed to the level where reasons for peoples actions are being consi dered,
where evidence is often not available and results are therefore not always repeatable.
978
C.5
979
C.5.1
980
981
CTM [12] is a systematic technique for analysing and graphically depicting the events and
conditions that contributed to a focus event.
982
983
984
The method examines all the system components associated with the focus event. The
investigation starts by establishing the tangible facts, taking care, in this phase, not to
interpret them or to express an opinion about them.
985
986
987
988
989
CTM is similar to the why method in concept but builds a more complex tree and explicitly
considers technical, organisational, human and environmental causes. Each antecedent
(identified cause) is tested to check it is a direct and necessary cause of the previous one
whereas the why method is less rigorous. Therefore, CTM is suitable for more complex
situations.
990
991
992
993
CTM is also similar to a fault tree but whereas a fault tree is used prior to an event to explore
all possible causes and strict logic relationship(s) between faults are specified, the cause tree
includes only those causes which apply to a specific event that has already occurred, and
does not develop the logical relationships in detail.
994
A cause tree may be used to explore successes as well as failures .
Causes Tree Method (CTM)

Overview
33
995
996
The Cause Tree forms a network of the causes which have directly or indirectly caused the
focus event, using the three logical relations shown in Figure C.5.
Sequence: A cause (Y) has a single direct
origin (X). i.e. (X) was necessary and
sufficient for (Y) to occur.
Conjunction A cause (Y) has several direct

origins (X1) and (X2). That means, each of
the direct origins (X1) and (X2) was
necessary for (Y) to occur.
X1
Y
X2
Disjunction or Separation: Two or more

causes (Y1;Y2, ) have a single and
identical direct origin (X). That means (X)
was necessary for (Y1) and (Y2) to be
produced.
Y1
X
Y2
997
Figure C.5 Symbols and links used in CTM
998
999
1000
1001
1002
1003
1004
1005
1006
1007
Figure C.6 shows an example tree, in which Mr L (the victim) and Mr A are working nights, as
an exception, to store a surplus of cooked matter stock. In accordance with the handbook, Mr
L and Mr A were required to load the cooked matter crusher with "flour" which is then bagged
and stored. Normally this activity is under the responsibility of a head of team whose
presence had not been considered essential by the management for this night. Of his own
initiative to save time Mr L took a forklift truck (the ignition key had remained on the
dashboard as usual) to store the bags. At the end of the task, Mr L set about returning the
forklift truck. Mr L carried out a sharp bend in reverse, forks raised and while seeking to avoid
a hole on the ground the forklift tipped over, crushing Mr L between the ground and the right
safety upright of the truck.
34
A hole is present in
the path of the
truck
L drives round the

hole in the floor
L puts the forklift

truck back where it
was
L & A have
finished storing the
bags (end of job)
L is on the floor
L turns while
reversing
The truck tips over
L is in the path of
the upright
L puts the forklift

truck away
L & A decide to
borrow the forklift
truck
L uses the forklift

truck for storing the
bags
L drives the truck

only very
occasionally
L reverses with the

forks raised
1008
1009
L is ejected from
the truck
Figure C.6 Example of a Cause Tree
The right upright of

the truck is present
L is crushed
between the floor
and the right safety
upright of the truck
35
1010
C.5.2
Process
1011
CTM has the following steps.
1012
1) Identify the focus event to be analysed and record as the starting point for the tree .
1013
1014
1015
2) Collect and record all relevant data including people, their activities, and actions,
materials and equipment and factors relating to the physical and psychosocial
environment.
1016
1017
1018
1019
1020
3) Make a list of the causal factors to the focus event. These should be supported by
evidence and be expressed as precisely as possible. Subjective opinions and judgements
are not included. Causal factors include those which are unusual or a change from the
normal course of events and those which are a normal but played an active part in the
occurrence of the event.
1021
1022
4) Work backwards towards the root causes by asking the following questions systematic ally
for each antecedent that has been gathered.
1023
a) What antecedent X has directly caused the antecedent Y?
1024
b) Was X in itself necessary to give rise to Y?
1025
1026
c)
If not, what are the other antecedents (X1, X2...) that were equally necessary in order
to give rise directly to Y?
1027
1028
1029
5) Display these immediate necessary causal factors in a box linked by an arrow to the focus
event. (The tree may be drawn horizontally or vertically but is normally drawn horizontally
starting from the right, so that left to right corresponds to the chronology of events).
1030
1031
6) Continue asking the same questions with respect to each cause found until the team
agrees that there is no value in continuing further.
1032
1033
7) Check the validity of the tree by obtaining further evidence that determines whether it is
true.
1034
C.5.3
1035
The strengths of CTM are as follows:
1036
provides a method for structuring investigation of complex events ;
1037
orderly easy to read format;
1038
can be used to encourage group participation ;
1039
identifies areas for collecting data as the in vestigation proceeds;
1040
can be used to analyse success or failure events ;
1041
can be used for technical and non-technical events.
1042
The limitations of CTM are as follows:
1043
1044
1045
many human and organisational factors may contribute to the occurrence of the focus
event and it is often difficult to establish which in a particular instance were the necessary
causal factors;
1046
1047
1048
there is no guidance on how to seek causes, therefore expertise in human error and
organisational systems is needed when the tree involves human and organisational
failures, where evidence is often difficult to obtain;
1049
1050
it is difficult to apply when an event occurs as a result in a change of quality in several

areas, where no single cause is a necessary cause.
1051
C.6
1052
C.6.1
1053
1054
1055
WBA [13] is a causal-analytical technique for establishing which of a given collection of

events and situations are necessary causal factors of which others. Given two events or
situations, A and B say, a condition called the Counterfactual Test (CT) is used to establ ish
Why-Because Analysis (WBA)

Overview
36
1056
1057
1058
1059
1060
1061
1062
whether A is a necessary causal factor of B. Suppose two events or situations A and B have
been observed. The CT asks whether, had A not occurred, B would also not have occurred.
(Since A did occur, a supposition that A had not occurred is contrary to fact, hence the word
counterfactual.) In asking this question all other conditions are assumed to have remained
the same. If the answer is yes: B would not have occurred then A is a necessary causal factor
of B. If the answer is no: B could have happened anyway even if A had not happened (the CT
fails) then A is not a necessary causal factor of B.
1063
1064
1065
1066
The network of causal-factors is displayed as a Why-Because Graph (WBG), a collection of

nodes, boxes, diamonds and other shapes, containing a brief descript ion of the fact, joined
by edges, or arrows, where the node at the tail of an arrow is a necessary causal factor of
the node at its head, as determined by the CT.
1067
1068
1069
A WBA is acyclic (contains no loops), so is usually drawn with arrows pointing in the gener ally
upwards direction, as above, or horizontally with arrows pointing generally left -to-right, or
right-to-left.
1070
1071
1072
1073
1074
1075
1076
1077
In order to determine whether sufficiently causal factors are present in the collection of events
and situations presented, the Causal Complet eness Test (CCT) is used. The CCT is applied
to a given event or situation and its collection of necessary causal factors as determined by
the CT. If the CCT is not passed, then the collection of events and situations must be
extended by further factors until it is passed. Suppose A 1 , A 2 ,...,A n have been determined to
be necessary causal factors of B by the CT. Then the CCT is deemed to be passed if, had B
not occurred, one of A 1 , A 2 ,...,A n would not have occurred either (formally, NOT-B is a
necessary causal factor of NOT( A 1 AND A 2 AND...AND A n) as determined by the CT).
1078
1079
1080
When a WBG has been constructed and the CCT is passed for all the events and situations
therein, then the WBG is complete and is deemed to represent a sufficient causal explanation
of the focus event.
1081
1082
Figure C.7 illustrates an example of a WBG for a commercial-aviation runway-overrun

accident.
1083
37
(11)
aircraft hits earth bank
(13)
earth bank in
overrun path
(12)
aircraft overuns runway
(16)
built by airport
authority for radio
equipment
(15)
unstabilized
approach
(14)
braking delayed
(18)
crews actions
(17)
wheel braking
delayed
(20)
aquaplaning
(25)
low weight on each
main gear wheel
(30)
excessive speed on
landing
(27)
condition of
runway surface
(19)
speed brakes & thrust
reversers deployment
delayed
(24)
runway very wet
(28)
weather
conditions
(29)
amount of water on
runway surface
(23)
braking systems
logical design
(22)
actual landing
(26)
behaviour
expected by
crew
(34)
crews actions in expectation of
windshear
(31)
crews training
at company X
1084
1085
Figure C.7 Example of a WBG
(21)
divergence between
consequences of design
& behaviour expected
by crew
(32)
company X
procedures
(33)
normal behaviour
expected by crew
38
1086
C.6.2
Process
1087
WBA has the following steps.
1088
1089
1) Determine a collection of facts deemed to be rel evant, under guidance of a stopping rule.
This gives an initial collection C of facts, divided into events, states and situations.
1090
2) Select the focus event (called in WBA the Accident Event) F.
1091
1092
3) Determine intuitively the immediate necessary causal factors of F from amongst the
collection C; check using the CT. Display the results visually as a partial WBG.
1093
1094
4) Determine intuitively the necessary causal factors of those immediate factors; check using
the CT. Extend the WBG with these factors.
1095
1096
5) Proceed to fill out the analysis (to extend the WBG) by testing each fact in C against the
factors already in the WBG.
1097
1098
6) Apply the CCT to determine whether the WBG is complete, or whether factors are missing
from the collection C.
1099
1100
1101
7) Extend C if necessary; incorporate the new facts into the WBG using the CT. If insufficient
information is available, assumptions may be included, providing they are clearly labelled
as such.
1102
1103
1104
8) Finish when the CCT shows sufficient causal factors for each factor, under cognisance of
the stopping rule. If insufficient facts are available, assumptions must be included in order
to allow the CCT to succeed, but clearly labelled as such.
1105
C.6.3
1106
The strengths of WBA are as follows:
1107
1108
1109
may be performed with a minimum of training (with the use of suitable tools that provide
help on extracting facts from narrative descriptions, an inexperienced analyst can typically
perform a first pass WBA inside two hours);
1110
the analysis results are easily understandable by third parties;
1111
1112
the conceptual background required to perform a WBA is limited (an analyst must be able
to apply the CT, and then the CCT);
1113
any network of causally-related phenomena may be analysed with a WBA;
1114
the reasoning behind a WBA may be formally checked using a formal logic;
1115
1116
can be used together with other methods; say, those providing more structure to the
collection of facts.
1117
The limitations of WBA are as follows:
1118
1119
1120
the method provides no guidance on the collection of facts to which the tests are applied
e.g. there is no structuring of facts into categories, for example technical, procedural,
human-factors, organisational and legal;
1121
1122
because facts are not structured, WBA provides limited guidance on corrective action, in
the case recurrence is to be prevented.
1123
C.7
1124
C.7.1
1125
1126
1127
1128
1129
1130
1131
1132
A Fault Tree [14] displays the immediate necessary causal factors of a focus event, their
causal predecessors and the logic relationships between them. Fault Tree Analysis (FTA) [15]
is normally used as a priori method of identifying and analysin g potential failure modes,
particularly of equipment. The fault tree diagram can be used in RCA by building a tree
following the same logic but including in the tree only those events which actually occurred.
OR gates may be used during the analysis to describe alternative causes that need to be
evaluated, but when all facts are clearly established only AND gates should remain, unless
the purpose of the investigation is to prevent other related events. Therefore, as the
Fault Tree and Success Tree Method

Overview
39
1133
1134
1135
investigation proceeds potential causes that do not fit the evidence are gradually ruled out
and removed from the tree. By closing out each branch of the tree, the causal factors of the
focus event become apparent.
1136
1137
1138
1139
Strictly a fault tree represents binary events where a statement is true or fa lse, e.g. a
component failed or not. In RCA the fault tree structure is often applied to a tree of causes
where the logic rules are not strictly obeyed and changes in quality are included as well as
binary events.
1140
1141
A similar logic can be applied where the focus event is a success. In this case the tree is
referred to as a success tree.
1142
Figure C.8 shows an example fault tree.
1143
Fire alarm fails
Signal to
solenoid fails
No power
source
Battery failure
Break in
circuit
Smoke
detector fails
Bell fails
Short circuit
Solenoid fails
Clapper stuck
Small
sensitivity to
smoke
Photoelectric
source fails
Mains failure
1144
Figure C.8 Example of a Fault Tree during the analysis
1145
1146
C.7.2
Process
1147
1148
1149
The process for developing a fault/success tree is as follows.
1150
1151
1152
2) Establish the immediate necessary causal factors of the focus event and display them in a
box linked by an arrow to the focus event. (The tr ee may be drawn horizontally or
vertically). These are the first level causes of the focus event.
1153
1154
1155
1156
3) Establish the logic relationships between the immediate causes using AND and OR Gates.
The events at an AND gate must be both necessary and sufficient to cau se the event
above. OR gates may be used during the analysis to describe potential causes that
require investigation.
1157
1158
4) Examine each cause to decide whether it is a basic cause or the result of underlying
causes.
1159
5) Validate potential causes and update the tree accordingly.
1) Define the focus event to be analysed and record it as the starting point for the tree.
40
1160
6) Continue down the tree until the stopping rule is reached.
1161
1162
1163
When the tree is developed the possibility of causal factors relating to people, equipment and
the environmental are considered for each cause at each level. These should not be
separated out at the top of the tree.
1164
C.7.2.1
1165
The strengths of the fault/success tree method are as follows:
1166
provides a method for dividing up the analysis for large complex focus events;
1167
1168
supported by many commercial software packages which as sist in the development of the
fault tree structure;
1169
encourages group participation;
1170
uses an orderly, easy-to-read format;
1171
identifies areas for collecting data.
1172
The limitations of the fault/success tree method are as following:
1173
requires an experienced practitioner;
1174
1175
has no underlying model of causation and provides no guidance on how to seek causal
factors;
1176
1177
1178
does not easily represent situations where an event occurs as a result of a general
changing of quality that affects for example adherence to procedures or tolerances of
physical components.
1179
C.8
1180
C.8.1
1181
1182
1183
1184
1185
1186
The Fishbone or Ishikawa Diagram [16] is a technique that helps identify, analyse and present
the possible causes of a focus event. It may be used to structure a brainstorming sess ion and
to suggest ideas where further evidence may be sought. The technique was invented by
Kaoru Ishikawa and graphically illustrates the relationship between an event and all the
factors that influence it. This technique is also referred to as a "fishbo ne diagram" because of
its appearance.
1187
Figure C.9 shows an example Fishbone or Ishikawa Diagram.
Fishbone or Ishikawa Diagram

Overview
41
Methods
Machinery
Cause
Cause
Reason Reason
Cause
Effect
Cause
Cause
Cause
Reason
Cause
Cause
Cause
Cause
Management
Materials
Manpower
1188
Figure C.9 Example of a Fishbone diagram
1189
1190
C.8.2
Process
1191
The process for developing a Fishbone or Ishikawa Diagram is as follows.
1192
1193
1) Identify the focus event and record it on the right hand side and draw a line horizontally
from it. This forms the head and spine of a fish.
1194
1195
2) Establish the main categories of causes to be considered: and draw lines off the spine to
represent each category. Categories commonly used include:
1196
a) 5Ms: Methods, Machinery, Management, Materials, Manpower;
1197
b) 4Ps: Place, Procedures, People, Policies;
1198
c) 4Ss: Surroundings, Suppliers, Systems, Skills.
1199
1200
1201
1202
3) For each category identify the possible causes of the focus event. These are presented as
smaller lines coming off the 'bones' of the fish. Increasingly more detailed levels of causes
can be shown as sub-branches coming off each cause line. It may be necessary to break
the diagram into smaller diagrams if one branch has too many sub -branches.
1203
1204
1205
4) Analyse the diagram: The diagram now shows all the possible causes of the focus event.
The final step is to investigate the most likely causes which tests whether the analysis is
correct. Analysis includes:
1206
1207
a) reviewing the balance of the diagram, checking for comparable l evels of detail to
identify the need for further identification of causes;
1208
b) identifying causes that appear repeatedly as these may represent root causes;
1209
1210
c) assessing what can be measured in each cause in order to quantify the effects of any
changes made;
1211
d) highlighting the causes whose action can be taken.
42
1212
C.8.3
1213
The strengths of the Fishbone or Ishikawa Diagram are as follows:
1214
encourages group participation to identify people s perceptions of causes;
1215
1216
seeks causes under a set of categories, so will identify a range of causes relating to
human and organisational factors as well as hardware and procedural factors;
1217
uses an orderly, easy-to-read format;
1218
indicates possible causes of variation;
1219
can be used for simple investigations or as part of a mo re complex investigation.
1220
The limitations of the Fishbone or Ishikawa Diagram are as follows:
1221
1222
1223
C.9
1224
C.9.1
1225
1226
1227
1228
SOL [17] is an event analysis technique, which seeks weaknesses in the complex sociotechnical system in which the event occurred. The purpose of SOL is to provide a model of
the system and identify its weaknesses so it can be improved and recurrence of the focus
event prevented. The emphasis is on organisational learning.
1229
C.9.2
1230
SOL has the following steps:
1231
1232
1) Starts with a description of the situation using a Time-Actor Matrix produced by

MES/STEP (see C.3).
1233
1234
1235
1236
1237
2) Causal factors (which may be direct or indirect see Table C.1) are identified for each
event in the Time-Actor Matrix, guided by checklists of questions derived from the
experience and research of SOL authors. Direct causal factors are those that immediately
resulted in the focus event, indirect causal factors appear further down the causal chain
but may involve the same issues.
1238
1239
3) Causal factors are classified into technology, individuals, working group, organisation, and
organisational environment.
there is no underlying model or theory of causation, so the causes identified are based on
the teams perceptions.
Safety through Organisational Learning (SOL)

Overview
Process
43
Table C.1 Direct and indirect causal factors
1240
Direct causal factors
Indirect causal factors
Information
Information
Communication
Communication
Working conditions
Working conditions
Personal performance
Personal performance
Violations
Violations
Technical components
Scheduling
Responsibility
Control and supervision
Group influence
Rules Procedures and documents
Qualifications
Training
Organisation and Management
Safety principles
Quality management
Maintenance
Regulatory and consulting bodies
Environmental influences
1241
C.9.3
1242
The strengths of SOL are as follows:
1243
1244
the check list format allows users who are not specialists in organisational systems or
organisational psychology to produce useful analyses;
1245
1246
1247
the emphasis on causal factors other than necessary causal factors allows more factors to
be brought into consideration than a narrowly-causal analysis might do, and thereby offer s
more chance of identifying possible improvements;
1248
1249
the format of the event building blocks gives less scope to the judgement of individual
analysts and helps to give uniformity to SOL analyses;
1250
1251
the stopping rule is implicitly defined by the checklist questions: when these have been
answered, the information is deemed to be adequate .
1252
The limitations of SOL are as follows:
1253
1254
there is no specific notion of what is a causal factor other than what is implicit in the
checklist questions;
1255
1256
the level of detail is driven by the predetermined checklist of questions rather than the
perceived need;
1257
1258
the check list of questions was derived from research in the nuclear power industr y and
may be less suitable for other industries.
1259
C.10 Management Oversight and Risk Tree (MORT)
1260
C.10.1
1261
1262
1263
MORT [18] was first developed for analysing the root causes and causal factors for incidents
in the nuclear power and aviation industries in the USA, but no w has been applied in many
industries.
1264
1265
1266
1267
MORT is a pre populated tree based on a model of an organisations management system ,

which effectively provides a detailed check list for reviewing which parts of management and
control systems were less than adequate when the focus event occurred. The basic structure
of the tree is shown in Figure C.10.
Overview
44
1268
1269
Figure C.10 Example of a MORT diagram
1270
1271
1272
MORT assumes that a failure occurs as a result of oversights or omissions in either

management systems or the specific control factors which should have prevented the focus
event from occurring.
1273
1274
1275
1276
Ultimately failures in either branch in the tree occur because someth ing within the general
management systems (Information systems, design and planning, operational readiness,
maintenance or supervision) was less than adequate. Each box in Figure C.10 is developed
into a detailed tree structure showing factors that might have been less than adequate .
1277
C.10.2
1278
1279
1280
Analysis starts with the focus event and then works down the MORT tree in a lo gical manner
asking and responding to pre-questions in the MORT manual. Symbols on the MORT chart
are colour coded to indicate:
1281
there is no problem with an element (adequate);
1282
the element is giving rise to a problem (less than adequate);
1283
there is need for further enquiries.
1284
C.10.3
1285
The strengths of MORT are as follows:
1286
1287
provides comprehensive guidance for seeking all possible aspects of the system that were
not adequate at the time of the focus event;
1288
1289
less specialist expertise is needed than in some techniques because detailed guidance is
provided on possible causes;
1290
1291
identifies weaknesses in the system which might apply across a wide range of failure
scenarios.
Process
45
1292
The limitations of MORT are as follows:
1293
1294
explores weaknesses in the system in general that might have played a role in the focus
event rather than seeking direct or necessary causes;
1295
1296
a very large number of questions (around 1500) are asked, so the method is time
consuming and hence most appropriate for serious events ;
1297
1298
1299
unless the organisation to which it is applied is a high reliability organisation a very large
number of weaknesses are found which make defining an i mplementation program
difficult;
1300
tedious when first learning or applying the method.
1301
C.11 AcciMaps
1302
C.11.1
1303
1304
AcciMaps [19] is based on concepts of causation published by Rasmussen and Svedung [20]
and the organisational systems model (see B.4).
1305
1306
1307
1308
1309
1310
AcciMaps is a graphical representation used to structure the analysis of a focus event and to
identify the interactions in the socio-technical system in which the focus event occurred. It is a
method designed to reveal the system wide failures, decisions and actions involved in a focus
event. These are arranged in layers representing the different levels in a socio -technical
system from government down to the equipment and surroundings involved. It also looks at
the individual actors at each level and their decision making routines and competence .
1311
1312
1313
1314
1315
1316
An example AcciMap for a gas explosion, showing typical system levels, is given in Figure
C.11. The bottom level represents the physical arrangement of the scene of the focus event
(buildings, equipment, surroundings etc.). The next level up is the sequence of events leading
to the focus event including the failures, actions and decisions (including no rmal actions and
decisions) that played a part. The higher levels show decisions and actions at each level that
influenced or could have influenced the sequence of events at the lower levels.
1317
C.11.2
1318
An AcciMaps is developed as follows.
1319
1) Define a model of the system with different organisational levels.
1320
1321
2) Populate the levels (using boxes (nodes)) with the decisions and actions relevant to the
focus event, the conditions that lead to them and their consequences.
1322
3) Draw arrows that show all linkages and influence s.
1323
1324
4) A process such as WBA may be added to ascertain which of the identified issues were
necessary causal factors of the focus event.
Overview
Process
46
1325
1326
Figure C.11 Example of an AcciMap
47
1327
C.11.3
Strengths and weaknesses
1328
The strengths of AcciMaps are as follows:
1329
1330
as there is no taxonomy or guidance, AcciMaps has the potential to be highly

comprehensive to identify causal factors across all levels of the system;
1331
1332
the linkages within and between levels helps ensure that failures are considered in the
context of the things that influenced them;
1333
human error has equal focus with equipment and higher level organisational factors ;
1334
personal factors which influence decisions particularly at the lower levels are not included .
1335
The limitations of AcciMaps are as follows:
1336
1337
the lack of a taxonomy means that the factors identified are based on the teams
perception;
1338
1339
the organisational model comes from outside the analysis and there is no criterion to
ensure it is adequate;
1340
1341
the result of the AcciMaps analysis is lightly constrained, therefore it is possible to derive
different AcciMaps for the same focus event;
1342
1343
with no specific taxonomy it is difficult to aggregate multiple analyses to find common

factors;
1344
1345
the generality of factors in the nodes is often high and can be very abstract. This makes it
difficult to derive precise actions;
1346
it has a weak analytical approach to physical and equipment failures ;
1347
it does not represent the results of a causal analysis by itself.
1348
C.12 Tripod Beta
1349
C.12.1
1350
1351
1352
1353
1354
1355
Tripod Beta [21] is an incident investigation and analysis methodo logy which combines the
ideas from Reasons model (see B.3) and Barrier Analysis (see B.2), along with Rasmussens
Generic Error Modelling System (GEMS) and Wagenaars Tripod causation path. It describes
incidents in terms of objects e.g. people, equipme nt, etc. being changed by agents of
change, e.g. anything with the potential to change an object. It also models barriers,
showing them as, for example effective, failed or inadequate barriers.
1356
1357
1358
1359
1360
1361
Tripod Beta provides a format and rules for modelling the events (focus event and the events
leading up to, and after, the focus event) and linking each element together, working back
ultimately to the underlying causes. A number of software packages have been developed
based on these rules, but it can be used w ith or without software. The softwarebased
techniques contains checklists derived from the models and from analysis of past events
mostly in the off shore oil industry.
1362
1363
The core of a Tripod analysis is a tree diagram representation of the causal network (see
Figure C.12) which describes the focus event as a network of events and their relationships.
Overview
48
1364
Figure C.12 Example of a Tripod Beta tree diagram
1365
1366
C.12.2
Process
1367
The process for developing the Tripod Beta tree diagram is to identify the following.
1368
1369
1) The agent (hazard or hazards) that lead to the focus event and the target that was
harmed.
1370
1371
2) Controls or barriers, that were missing or failed, that could have prevented the event or
protected the target.
1372
1373
1374
3) Immediate causes - the human act, which resulted in the failed barrier. These are failures
or errors that have immediate effect and occur at the point of contact between a human
and a system (e.g. pushing an incorrect button, ignoring a warning light) .
1375
1376
4) Preconditions - psychological and situational precursors e.g. the type of human failure
(slip, lapse, violation, etc.).
1377
1378
1379
1380
5) Underlying causes (latent failures) in the organisation, i.e. inadequacies in the

management system, culture, etc. These can be categorised into pre -defined basic risk
factors, derived from brainstorming and research into results of audits and accident
investigations in the Off Shore Oil Industry.
49
1381
C.12.3
1382
The strengths of the Tripod methodology are as follows:
1383
provides a map of the focus event and its causes;
1384
can help direct the investigation and define its scope;
1385
defines the barriers in the system;
1386
1387
based on scientific research including a model of human behaviour to uncover what i s

behind the observed behaviour;
1388
1389
leads the investigator to consider the reasons behind the immediate causes and human
error;
1390
menu driven software is available.
1391
The limitations of the Tripod methodology are as follows:
1392
can be resource intensive;
1393
1394
leads to system level underlying causes which an organisation might not be able to
accept;
1395
1396
use of the Basic Risk Factors to categorise underlying causes can be too generic and
simplistic;
1397
conclusions do not lead to simple remedial actions;
1398
extensive training is generally required.
1399
C.13 Casual Analysis using STAMP (CAST)
1400
C.13.1
1401
1402
1403
1404
1405
1406
CAST [7] is a technique that examines the entire socio-technical process involved in a focus
event. CAST is based on STAMP (see B.5), which is used to guide the causal analysis. CAST
documents the dynamic process leading to the focus event including the socio -technical
control structure as well as the constraints that were violated at each level of the control
structure and why. The analysis results in multiple views of the focus event, depending on the
perspective and level from which the focus event is being viewed.
1407
1408
1409
1410
1411
1412
1413
1414
1415
1416
To illustrate CAST, consider a focus event involving the contamination of a public water
supply with E. coli in a small town in Ontario, Canada. Figure C.13 shows the safety control
structure for the water supply of the town. There are three physical systems being controlled:
the well system, the water supply, and public health. Each component in the structure
controlling these processes has specific safety-related responsibilities. For example, the
Ministry of the Environment provides oversight and control of the local water systems. Each
component of the control structure gets feedback about the state of the process it is
controlling. One common cause is that the controller gets incorrect feedback and thinks the
state of the controlled process is different than it is. For example, budgets were cut and the
Ministry of the Interior reduced the number of inspections and inspectors.
1417
1418
1419
1420
1421
Figure C.14 shows the analysis of the role of the local health department in the focus event,
including the roles and responsibilities, the unsafe control actions, the context in which the
unsafe control actions were provided, and the flaws in the process (mental) model that
contributed to the behaviour. Figure C.15 shows the same thing for another component of the
control structure, the water system operations mana gement.
1422
1423
1424
In a full analysis, each component of the control structure would be considered with respect to
their contribution to the focus event. In most focus events, contributions can be found from
every component of the control structure.
1425
1426
1427
Other features of the analysis (not shown) include examining the dynamic changes over time
in the system that contributed to the focus event and the role of flawed communication and
coordination.
Overview
50
1428
1429
Copyright Nancy Leveson, Aug. 2006
Figure C.13 Control structure for the water supply in Walkerton, Canada.
BGOS Medical Department of Health
Safety Requirements and Constraints:
Provide oversight of drinking water quality
Follow up on adverse drinking water quality
reports
Issue boil water and other advisories if public
health at risk
Context in which decision made:
Most recent water quality reports over 2 years
old
Illness surfacing in communities outside
Walkerton
E. coli most commonly spread through meat
Mental Model Flaws:

Thought adverse water quality reports
were being received
Unaware of reports of E. coli linked to
treated water
Thought Mr K was relaying the truth
Unaware of poor state of local water
operations
Coordination
Assumed the Ministry of Environment
was
ensuring
inspection
report
problems were resolved
Inadequate control actions:

Advisory delayed
Advisory should have been more widely
disseminated
Public health inspector did not follow up on
1998 inspection report
1430
Figure C.14 Example CAST causal analysis for the local Department of Health
51
Walkerton PUC Operations Management
Safety Requirements and Constraints:
Monitor operations to ensure that sample
taking and reporting is carried out
Keep accurate records
Update knowledge as required
Context in which decision made:
Complaints by citizens about chlorine taste in
drinking water
Improper activities were an established
practice for 20 years
Lacked adequate training and expertise
Mental Model Flaws:

Believed sources for water system
were generally safe
Thought untreated water was safe to
drink
Did not understand health risks posed
by under chlorinated water
Did not understand risks of bacterial
contaminants like E. coli
Did not believe guidelines were a
high priority
Inadequate control actions:

Inadequate monitoring and supervision of
operations
Adverse test results not reported when asked
Problems discovered during inspections not
rectified
Inadequate response after first symptoms in
community
Did not maintain proper training or operations
records
1431
1432
Figure C.15 Example CAST causal analysis for the local public utility operations
management
1433
C.13.2
Process
1434
CAST has the following steps.
1435
1) Identify the system(s) involved in the focus event.
1436
2) Identify the system constraints associated with the focus event.
1437
1438
1439
1440
3) Document the control structure in place. This structure includes the roles and
responsibilities of each component in the structure as well as the controls provided or
created to execute their responsibilities and the relevant feedback (if any) provided to help
them do this.
1441
4) Determine the proximate events leading to the focus ev ent.
1442
1443
1444
1445
5) Analyse the focus event at the physical system level. Identify the contribution of each of
the following to the events: physical and operational controls, physical failures,
dysfunctional interactions, communication and coordination flaws, and unhandl ed
disturbances. Determine why the physical controls in place were ineffective.
1446
1447
1448
6) Moving up the levels of the control structure, determine, as follows, how and why each
successive higher level allowed or contributed to the inadequate control at the current
level.
1449
1450
1451
1452
a) For each system constraint, either the responsibility for enforcing it was never
assigned to a component in the control structure or a component (s) did not exercise
adequate control to ensure their assigned responsibilities were enforced in the
components below them.
1453
1454
b) Identify unsafe decisions or control actions, including actions provided by software,

operators, managers, regulators, etc.
1455
1456
1457
1458
1459
1460
c) Any human decisions or flawed control actions need to be understood in terms of the
information available to the decision maker as well as any information that was not
available, the behaviour shaping mechanisms (the context and influences on the
decision making process), the value structures underlying the decision, and any flaws
in the process models (mental models) of those making the decisions and why those
flaws existed.
52
1461
1462
7) Examine the overall coordination and communication (including missing feedback) that
contributed to the focus event.
1463
1464
Although the process is described in terms of steps, the process need not be linear nor must
one step be completed before the next one is started.
1465
C.13.3
1466
The strengths of CAST are as follows:
1467
looks back through time to determine how the system evolved to a state of high risk;
1468
1469
identifies the social and managerial factors and not just the human operations or technical
system failures;
1470
1471
does not impose any particular social theory on the analysis, any model of social
behaviour could be used to generate the analysis results.
1472
The limitations of CAST are as follows:
1473
1474
1475
it is not possible to graphically present the analysis, as the inclusion of indirect

relationships between causal factors means that circles and arrows (which depict direct
relationships) are not adequate to describe all the causal factors ;
1476
1477
may require more resources and time to fully understand the focus event than other
methods with a more limited focus.
1478
1479
53
Annex D
(Informative)
1480
1481
1482
1483
Useful tools to assist RCA
1484
D.1
General
1485
This Annex describes tools and techniques that can support the conduct of RCA.
1486
D.2
1487
D.2.1
1488
1489
1490
1491
1492
Modern data mining techniques enable a search for specific properties and conditions.
Clustering analysis selects data that are closely related, and thereby identify deviating data
(outliers). Modern cluster analysis can detect data t hat are closely related in one, two or more
dimensions and thereby analyse products or processes that are closely related and identify
deviating data points (outliers).
1493
1494
1495
1496
1497
In RCA data mining and clustering analysis can give valuable clues and help to confirm or
reject potential root causes. In some cases e.g. aerospace and medical equipment it is
required to store batch numbers for the finished products and the associated component
batch numbers and raw material batch numbers. This information can provide a us eful
structure for identifying correlations which hint at possible causal relations.
1498
D.2.2
1499
1500
1501
1502
1503
1504
1505
1506
1507
1508
1509
1510
1511
1512
1513
1514
1515
1516
1517
1518
1519
1520
A company observes 12% failures of stocked items. Analysis showed that a plastic part is
broken. The start of the 12% failure pattern is identified as a batch nu mber and a
manufacturing date. This date is correlated with delivered batches of the plastic parts. There
is no correlation. There is no correlation either to the batches of plastic raw materials.
However there is a correlation with the batches of a spring that load the plastic part. The
problem started 3 days after a new batch of springs was received. It is investigated what
changes were made between this batch of springs and the previous batches. The difference is
a new surface treatment against corrosion. This surface treatment process is investigated
and contains a note that this treatment may interfere with certain plastic materials. Further
analysis show that the corrosion protection accelerates crack propagation in this plastic.
Analysis of the data sheet for the plastic material showed a warning against local overload
that may cause cracks. So the conclusion is that a causal hypothesis can be formulated: that
a plastic part is continuously overloaded and undergoes fracture through local overload, whi ch
fractures propagate in a manner accelerated by the new anti -corrosion treatment of the
springs. These cracks are then propagating accelerated by the new anti-corrosion treatment
of the springs. A failure analysis have previously shown a pattern on the f racture surface
consisting of crack propagation lines originating in the points of contact with the spring and a
brittle surface from the final fracture. The causal-explanatory hypothesis may be confirmed to
a given level of confidence by experiment: setti ng up a number of plastic parts with and
without the new treatment. If it is observed that plastic parts with the new treatment
predominantly fail, one may conclude that the causal hypothesis is confirmed to the
appropriate degree of confidence using stand ard methods of statistical inference.
1521
D.2.3
1522
1523
1524
1525
1526
1527
1528
1529
A number of soldering failures is observed in the field. The manufacturing weeks for the failed
products are plotted in calendar time. It is observed that the manufacturing dates of the
products with soldering failures are clustering in certain weeks. A causal hypothesis may be
formulated on the basis of the initial observation, which is then confirmed to a given degree of
confidence using standard statistical inference on the process -control data from
manufacturing, which indicate that the soldering process in these weeks was likely not
performed under appropriate control. The conclusion is, to a high level of confidence, that a
root cause of the soldering failures is insufficient process control of the solde r process.
Data mining and clustering techniques

Overview
Example 1
Example 2
54
1530
D.2.4
Example 3
1531
1532
1533
1534
1535
1536
1537
1538
1539
1540
A component is tested on a test board by twisting the board. The number of twist to failure is
plotted on a Weibull plot (see IEC 61649). The analysis identifies a weak and a strong
population (see IEC 61163-1). One component from the weak and one component from the
strong population is analysed by cross sectioning of the micro Ball Grid Array (BGA) solder
balls. It is noted that the component from the weak population have a large number of large
voids in the solder balls, while the solder balls from the strong population have no or few
small voids. It is concluded that a root -causal hypothesis is formulated, that voids in the
solder balls of the micro BGA are a root cause of the incident events. The root -causal
hypothesis is confirmed by collecting data on operational use and observing through analysis
of the data that the reduction in voids correlates with successful use of the component .
55
Annex E
(Informative)
1541
1542
1543
1544
Analysis of human performance
1545
E.1
General
1546
1547
1548
1549
People at any level in an organisation make decisions or perform or omit actions which may
play a part in the events leading to a focus event. Human performance may be above or
below expectation and the impact may be positive or negative. Decisions can be correct in the
circumstances in which they were made but turn out to have unintended results.
1550
1551
1552
1553
People may make errors, be misguided or misinformed, be inappropriately motivated, may be

trying to perform correctly or may knowingly violate rules. Analysis of human aspects of
causation is complex and generally requires specialist expertise if it is required to go beyond
identifying what occurred to seeking why and hence making recommendations.
1554
E.1.1
1555
1556
1557
Analysis of human failures starts by identifying the error mode. This is the extern al
manifestation of the error i.e. what is observed to be done (or not done). Examples of error
modes are:
1558
omitted;
1559
too early;
1560
too late;
1561
too much;
1562
too little;
1563
wrong direction;
1564
wrong object;
1565
wrong action;
1566
wrong sequence.
1567
1568
1569
1570
There are then a number of different taxonomies for categorising and analysing causes of
these errors. They differ in the number and types of classifications they consider and in the
models of human behaviour on which the taxonomies are based and on where the most
emphasis is placed. The following are generally considered.
1571
1572
1573
1) The internal error mode and error mechanism. This is the reasons behind the error in
psychological meaningful terms e.g. for an error mode of took wrong turn in car , the
internal error mode and mechanism might be incorrect decision due to habit intrusion.
1574
1575
2) Inherent problems of the task e.g. conflicting goals, planning problems, constraints,
cognitive demands etc.
1576
1577
1578
3) Performance Shaping Factors (PSF). These are the conditions of the technical or
organisational environment or internal to a person which affect how well a task will be
performed (See IEC 62508 Human aspects of dependability [22]).
1579
1580
1581
1582
1583
1584
Some models also include an analysis of the flow of information and feedback without which
correct judgements are unlikely to be made. The importance of these methods is that they first
identify the psychological error mechanism before identifying why the error was made. For
example if the error mechanism is not due to a lack of knowledge or skill then further training
is unlikely to be useful. If a decision is made to violate a procedure then the reasons why this
occurred should be investigated rather than assuming increased supervision is the solution.
Analysis of Human failure
56
1585
1586
Two examples of methods which can be used to analyse the causes of human failure which
illustrate these principles are:
1587
Technique for Retrospective and Predictive Analysis of Cognitive Errors (TRACEr) ;
1588
Human Factors Analysis and Classification Scheme (HFACS) .
1589
1590
E.2
1591
E.2.1
1592
1593
TRACEr [23] was developed for use in air traffic control. TRACEr, has eight modules as
shown in Figure E.1, which can be divided into the following three categories:
1594
1595
the context in which the error occurred i.e. the nature of the task, the environment and the
PSFs;
1596
1597
1598
the production of the error i.e. the External Error Modes (EEM), Internal Error Modes
(IEM), the Psychological Error Mechanisms (PEM) and the information on which the
individual based their actions;
1599
the detection and correction of the error .
1600
1601
1602
The error production modules are based on the cognitive processes involved when a person
perceives something needs to be done and takes action e.g. perception, memory, decision
making and action (see Figure E2).
Technique for Retrospective and Predictive Analysis of Cognitive Errors

(TRACEr)
Overview
Environment
Task
What task failed? E.g. Radar monitoring error
Task Error
How was the error recovered?
E.g. Plan modification
Correction
EEM
What happened?
E.g. Action omitted
Information
How was the error detected?

E.g. Outcome feedback
Detection
What did the controller detect late? E.g. FL

IEM
What perceptual function failed and in what way did it fail?
E.g. late visual detection.
PEM
How did the error occur?
E.g. perceptual tunnelling
Cognitive Domains
1603
1604
1605
Figure E.1 Example of an TRACEr Model [23]
PSF
What other
factors
contributed to
the errors or
recovery?
E.g. Traffic
complexity
57
Cognitive Domain
Cognitive Function
Relevant
Keywords
Detection
None, late,
incorrect
Late detection
Identification
None, late,
incorrect
Misidentification
Recognition/Comparison
None, late,
incorrect
Hearback error
Recall perceptual information
None, incorrect
Forget temporary
information
Previous action
None, incorrect
Forget previous
actions
Immediate/current action
None, incorrect
Forget to perform
action
Prospective memory
None, incorrect
Prospective
memory failure
Stored information (procedural and declarative

knowledge)
None, incorrect
Mis-recall stored
information
Judgement
Incorrect
Misprojection
Planning
None, too little,

incorrect
Underplan
Decision making
None, late,
incorrect
Incorrect decision
Timing
Early, late, long,

short
Action too early
Positioning
Too much, too little,

incorrect, wrong
direction
Positioning error,
overshoot
Selection
Incorrect
Typing error
Communication
None, unclear,
incorrect
Unclear information
transmitted
Vision
Perception
Hearing
Memory
Judgement,
Planning and
Decision Making
Action
Execution
Example IEM
Figure E.2 Generation of Internal Error modes
1606
1607
E.2.2
Process
1608
A TRACEr model is created using the following steps.
1609
1610
1611
1) Analyse the task being carried out and identify any environmental or situational factors
that might affect human performance (PSFs), which includes task complexity, knowledge
and experience of the person, the ambient environment etc.
1612
1613
2) Identify EEMs, which are classified in terms of selection and quality, timing and sequence,
and communication (see Table E.1).
1614
1615
3) Identify the IEMs, which describe what cognitive function failed and in what way, the
taxonomy for which is shown in Figure E.2.
1616
1617
4) Identify the information issues associated with the IEM i.e. what i nformation was
misperceived, forgotten, misjudged or mis-communicated.
1618
1619
5) Identify the PEMs, which are the cognitive biases known to affect performance within each
cognitive domain (see Table E.2).
1620
1621
1622
6) Review the error detection process, which is how the person became aware of the error,
what medium informed them of the error and what external factors improved or degraded
detection.
1623
1624
7) Consider correction i.e. what was done to correct the error, did other factors internal or
external improve or degrade the error corr ection.
58
Table E.1 External Error Modes
1625
Selection and quality
Timing and sequence
Communication
Omission
Action too little
Action too much
Action in wrong direction
Right action wrong object
Wrong action on right object
Wrong action wrong object
Extraneous act
Action too long

Action too short
Action too early
Action too late
Action repeated
Mis-ordering
Unclear information transmitted

Unclear information received
Information not sought/obtained
Information not transmitted
Information not recorded
Incomplete information transmitted
Incomplete information received
Incomplete information recorded
Incorrect information recorded
Table E.2 Psychological Error Mechanisms
1626
Perception
Memory
Decision making
Action
Expectation bias
Similarity interference
Incorrect knowledge
Manual variability
Spatial confusion
Memory
overload
Lack of knowledge
Perceptual confusion
capacity
Negative transfer
Failure
effects
Mis-learning
Integration failure
Perceptual tunnelling
Insufficient learning
Misunderstanding
Stimulus overload
Infrequency bias
Cognitive fixation
Vigilance failure
Memory block
False assumption
distraction
Distraction
/preoccupation
Prioritisation failure
Perceptual
discrimination failure
to
consider
Spatial confusion
side
Habit intrusion
Perceptual confusion
Mis-articulation
Environmental intrusion
Other slip
Distraction
preoccupation
Risk negation or tolerance

Risk recognition failure
Decision freeze
1627
E.3
Human Factors Analysis and Classification Scheme (HFACS)
1628
E.3.1
1629
1630
1631
HFACS [24] was developed by behavioural scientists in the Unites States Navy and analyses
the causes of human error based on Reasons model ( see B.3). There are four levels of
consideration based on Reasons slices of Swiss cheese:
1632
organisational influences;
1633
supervision;
1634
preconditions for unsafe acts;
1635
unsafe acts.
1636
1637
Some applications add a fifth level above organisational influences relating to legislation and
government.
1638
E.3.2
1639
1640
1641
1642
Each level is subdivided into categories, and examples are given of possible causes within
the category. Different applications use the same categories (shown in the boxes below) but
may have different examples depending on the industry, and may provide a few examples or a
more detailed check list. Examples of the four levels are shown in Figure E.3 to E.6.
1643
1644
1645
Consideration of cause starts with Level 1 so that precursor s for the act in question take
account of the type of error involved then continues up through the levels seeking
weaknesses that contributed to the focus event.
Overview
Process
59
Unsafe Acts
Violations
Errors
Decision errors
actions of operators proceed as
intended but prove inadequate to
achieve required result E.g
followed inappropriate procedure
exceeded ability
Routine
(habitual tolerated
by management)
Exceptional
Isolated departure
from authority- not
tolerated
Skill based errors E.g

Omitted step
inadvertent operation of controls
fail to prioritise attention
Poor technique
Perceptual Error
Decision made based on faulty information
Misjudged distance/angles/speed
Spatial disorientation
Visual illusion
1646
Figure E.3 Level 1 Unsafe Acts
1647
Preconditions
Environmental
factors
Condition of
operators
Physical Environment
E.g.
weather
heat
lighting
noise
Technological environment.
E.g
design of equipment
displays and controls
human computer interface
Design of task
1648
1649
Physiological state
E.g .
illness
fatigue
intoxication
Psychological state
E.g
stress
motivation
haste
channelised attention
overconfidence
loss of situational awareness
Physical and mental limitations
E.g
insufficient reaction time
visual limitation
short term memory limittion
beyond skill level
Figure E.4 Level 2 Preconditions
Personal
Factors
Personal readiness
(off duty activities that
affect performance
Staff resource
management
E.g.
communication
planning
team work
60
Supervision
Planned
inappropriate
operations
Inadequate
supervision
E.g.failed to provide
leadership
oversight
incentives
guidance
training
Failed to
correct
problem
E.g
insufficient time allowed
insufficient opportunity for rest
inappropriate procedures
inadequate risk control
Supervisory
violation
E.g. failed to correct

document error
violation
E.g
inadequate documentation
Failed to enforce rules and
standards
Authorised unnecessary
risk taking
1650
Figure E.5 Level 3 Supervision Issues
1651
Organisational influences
Resource
management
Organisational
climate
Policies
HR
selection
staffing levels
training
Budget
Cost cutting
1652
1653
Equipment
Fit for purpose
Structure
chain of command
communication
formal accountability
Organisational
processes
Operations
Incentives
Pressures
Appraisal processes
Schedules
Procedures
Standards
Documentation
Instructions
Culture
Norms and rules
Values and beliefs
Oversight
Figure E.6 Level 4 Organisational Issues
61
1654
Bibliography
1655
1656
[1]
ISO Guide 73: 2009 Risk management Vocabulary
1657
1658
[2]
IEC 60300-1 ED.3, Dependability management, Part 1: Guidance for management an d

application
1659
1660
[3]
Haddon, W Jr.: Energy Damage and the Ten Counter-Measure Strategies, The Journal
of the Human Factors and Ergonomics Society, 1973
1661
[4]
Hollnagel, E.: Barriers and Accident Prevention, Ashgate Publishing Limited, 2004
1662
[5]
Reason, J.: Human Error Cambridge University Press, 1990
1663
1664
[6]
Checkland, P.: Systems Thinking, Systems Practice: Includes A 30-Year

Retrospective, Wiley Pages: 416, 1999
1665
[7]
Leveson, N.: Engineering a Safer World, MIT Press, 2012
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1667
[8]
Rasmussen, J.: Risk Management in a Dynamic Society: A Modelling Problem, Safety

Science Volume 27, Issue 2-3, Pages: 183-213, 1997
1668
1669
[9]
Technical Research and Analysis Center: Events and Causal Factors Analysi s, SCIEDOE-01-TRAC-14-95, 1995
1670
1671
[10]
Benner, L. Jr: Accident Investigations: Multilinear Event Sequencing Methods, Journ al

of Safety Research 7, 67-73, 1975
1672
1673
[11]
Hendrick, K. and Benner, L. Jr: Investigating Accidents wit h STEP, Marcel Dekker Inc,
1986
1674
1675
[12]
Monteau, M.: Analysis and reporting: accident investigation. Encyclopaedia of

Occupational Health and Safety, 57-22:26, ISBN 1:92-2-1-103290-6, 1982
1676
[13]
Sanders, J.: Introduction to Why-Because Analysis, 2012
1677
1678
[14]
US Nuclear Regulatory Commission: NUREG 0492, Fault Tree Handbook, January,

1981
1679
[15]
IEC 61025, Fault tree analysis
1680
[16]
Ishikawa, K.: Guide to Quality Control, Asia Productivity Organization, 1986
1681
1682
[17]
Fahlbruch, B. and Schbel, M.: SOL - Safety through organizational learning: A

method for event analysis. Safety Science, Volume 49, Pages 2731, 2011
1683
[18]
Johnson, W. and Dekker, M.: MORT Safety Assurance Systems, 1980
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1685
1686
[19]
Svedung, J. and Rasmussen, J.: Graphic representation of Accident Scenarios:

Mapping System Structure and the Causation of Accidents, Safety Science, Volume
40, Pages 397-417, 2002
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[20]
Svedung, J. and Rasmussen, J.: Risk Management in a Dynamic Society: A Modelling

Problem, Safety Science, Volume 27, Pages 183-213, 1997
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1690
1691
[21]
Energy Institute: Tripod Beta: Guidance on the use of Tripod Beta in the investigation
and analysis of incidents, accidents and business losses, 2013,
http:www.tripodfoundation.com.
1692
[22]
IEC 62508 Ed. 1.0 B: 2010, Guidance on human aspects of dependability
62
1693
1694
1695
[23]
Shorrock, S. and Kirwan, B.: Development and application of a human error

identification tool for air traffic control, Applied Ergonomics, Volume 33, Pages 319
336, 2002
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1697
1698
[24]
Shappell, S. and Wiegmann, D.: Applying Reason: The Human Factors Analysis and
Classification System (HFACS), Human Factors and Aerospace Safety, Volume 1,
Pages 59-86 , 2001
1699
[25]
ISO/IEC 31010 Ed. 1.0: Risk Management - Risk Assessment Techniques
1700
[26]
ISO 31000: 2009 Risk management Principles and guidelines
1701
1702
1703
1704
1705
1706
1707

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Draft BS EN 62740 Root Cause Analysis (RCA)

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IEC 62740/Ed1: Root Cause Analysis (RCA)

Copyright 2013 International Electrotechnical Commission, IEC . All rights reserved. It is

Normative references ...................................................................................................... 7

Terms and definitions ...................................................................................................... 7

Introduction to RCA ......................................................................................................... 9

The RCA process .......................................................................................................... 10

Figure 1 RCA process ........................................................................................................ 10

Figure C.1 Example of an ECF chart .................................................................................. 27

Figure C.2 Data in an event building block ......................................................................... 29

Figure C.3 Example of a Time-Actor Matrix ........................................................................ 30

Figure C.4 Example of a Why Tree .................................................................................... 31

Figure C.5 Symbols and links used in CTM ........................................................................ 33

Figure C.6 Example of a Cause Tree ................................................................................. 34

Figure C.7 Example of a WBG ........................................................................................... 37

Figure C.8 Example of a Fault Tree during the analysis ..................................................... 39

Figure C.9 Example of a Fishbone diagram ........................................................................ 41

Figure C.10 Example of a MORT diagram .......................................................................... 44

Figure C.11 Example of an AcciMap .................................................................................. 46

Figure C.12 Example of a Tripod Beta tree diagram ........................................................... 48

Figure E.1 Example of an TRACEr Model [23] .................................................................... 56

Figure E.2 Generation of Internal Error modes ................................................................... 57

Figure E.3 Level 1 Unsafe Acts .......................................................................................... 59

Figure E.4 Level 2 Preconditions ....................................................................................... 59

Figure E.5 Level 3 Supervision Issues ............................................................................... 60

Figure E.6 Level 4 Organisational Issues ........................................................................... 60

Table 1 Steps to RCA ........................................................................................................ 10

Table A.1 Brief description of RCA techniques ................................................................... 19

Table A.2 Summary of RCA technique criteria.................................................................... 20

Table A.3 Attributes of the generic RCA techniques ........................................................... 22

Table B.1 Examples of barriers .......................................................................................... 24

Table B.2 Example Barrier Analysis Worksheet .................................................................. 24

Table C.1 Direct and indirect causal factors ....................................................................... 43

Table E.1 External Error Modes ......................................................................................... 58

Table E.2 Psychological Error Mechanisms ........................................................................ 58

INTERNATIONAL ELECTROTECHNICAL COMMISSION

ROOT CAUSE ANALYSIS (RCA)

The text of this standard is based on the following documents: