Environmental Engineering Reference
In-Depth Information
and.they.help.set.up.the.accident..An.example.would.be.not.locking.the.gates.to.an.
electrical.substation.and.kids.wandering.onto.the.site.and.hurting.themselves.
BeneFIts oF events And cAusAl FActors chArtIng
The.beneits.of.events.and.causal.factors.charting.include
•. Illustrating. and. validating. the. sequence. of. events. leading. to. the. accident.
and.the.conditions.affecting.these.events
•. Showing.the.relationship.of.immediately.relevant.events. and. condition. to.
those.that.are.associated.but.less.apparent—portraying.the.relationships.of.
organizations.and.individuals.involved.in.the.accident
•. Directing.the.progression.of.additional.data.collection.and.analysis.by.iden-
tifying.information.gaps
•.
Linking. facts. and. causal. factors. to. organization. issues. and. management.
systems
•.
Validating.the.results.of.other.analytic.techniques
•.
Providing. a. structured. method. for. collecting,. organizing,. and. integrating.
collected.evidence
•.
Conveying.the.possibility.of.multiple.causes
•.
Providing.an.ongoing.method.of.organizing.and.presenting.data.to.facilitate.
communication.among.the.investigators
•.
Clearly.presenting.information.regarding.the.accident.that.can.be.used.to.
guide.report.writing
•.
Providing.an.effective.visual.aid.that.summarizes.key.information.regard-
ing.the.accident.and.its.causes.in.the.investigation.report.
usIng cAusAl FActor AnAlysIs
(event FActor chAIns or chArtIng)
C
onstruCting
tHE
C
HArt
Constructing.the.events.and.causal.factors.chart.should.begin.immediately..However,.
the.initial.chart.will.be.only.a.skeleton.of.the.inal.product..Many.events.and.con-
dition.will.be.discovered.in.a.short.amount.of.time;.therefore,.the.chart.should.be.
updated.almost.daily.throughout.the.investigative.data.collection.phase..Keeping.the.
chart.up-to-date.helps.ensure.that.the.investigation.proceeds.smoothly,.that.gaps.in.
information.are.identiied,.and.that.the.investigators.have.a.clear.representation.of.
the.accident.chronology.for.use.in.evidence.collection.and.witness.interviewing.
The.investigator.and.analyst.can.construct.an.event.and.causal.factors.chart.using.
either. a. manual. or. computerized. method.. Accident. investigation. teams. often. use.
both.techniques.during.the.course.of.the.investigation,.developing.the.initial.chart.
manually.and.then.transferring.the.resulting.data.into.a.computer.program.
The. manual. method. may. employ. removable. adhesive. notes. to. chronologically.
depict. events. and. the. conditions. affecting. the. events.. The. chart. is. generally. con-
structed.on.a.large.conference.room.wall.on.many.sheets.of.poster.paper..Accident.
