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SACA. The analyst must work systematically through the ‘checklist’ and judge firstly, whether the causal factors presented were applicable to the incident and secondly, for those that are found to be applicable, whether they were necessary and sufficient to be one of the contributory causes of the incident. 1. (Those methods from Section 5 have not been included because they only identify direct causal factors rather than root cause factors. Methods outlined in Section 8 have been omitted either because there is insufficient information on the technique, or because the methods described are not considered to be true root causes analysis methodologies).

These include Events and Causal Charting, Fault Tree Analysis, Change Analysis, Barrier Analysis as well at HPES. Smith (1988) states that the development of HPES was heavily influenced by the MORT technique. This technique is well supported with training, documentation and advisory service from INPO. Feedback of the results of investigations within the forty installations operating this system occurs regularly through the publication of newsletters and a database. However, INPO have placed restrictions on the use of their documentation and root cause analysis technique.

Group techniques such as this do, however, present benefits to the organisation in terms of team building, increased awareness of safety issues and ownership of resulting actions. The incorporation of logic into prescriptive tree structures would not appear to lend much benefit. They make the system more complex than necessary and increase the training requirements considerably. Discussing MORT, Ferry (1988) states that ‘Unfortunately people do not learn MORT well in these ‘all talk’ seminars. It has been found that firsthand use of the tool and a high degree of familiarity are necessary to develop proficiency’.

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