ABSTRACT

Accidents are rarely simple and almost never result from a single cause. Accidents may develop from a sequence of events involving performance errors, changes in procedures, oversights, and missions. Events and conditions must be identified and examined to find the cause of the accident and a way to prevent that accident and similar accidents from occurring again. By creating an event in the causal factor chain, multiple causes can be visually illustrated, and a visual relationship between the direct and contributing causes can be shown. Event causal charting also visually delineates the interactions and relationships of all involved groups or individuals. By using root cause analysis, one can develop an event causal chain to examine the accident in a step-by-step manner by looking at the events, conditions, and causal factors chronologically, to prevent future accidents.