Tracing Techniques
To help initially identify the direct and contributing events, it is generally best to work backward from the point of the accident to the initiating event. This approach is known as the "backward tracing" or "reverse tracing" method, and it involves tracing events back to the point of origin.
The backward tracing method can be effective because it allows investigators to identify the surface causes (behaviors and conditions) in each event. It can also help in identifying the underlying factors that contributed to the accident and to develop effective corrective actions to prevent similar accidents from happening in the future.
Below are the steps involved in the backward tracing method for identifying events:
- Identify the accident and gather the facts: What happened, where it happened, who was involved, and what the outcome was.
- Identify the immediate and surface causes: Identify the immediate cause of the injury/fatality and the surface causes that led directly to the accident. Surface causes include unique unsafe acts and hazardous conditions.
- Identify the contributing root causes: Identify the contributing causes that led to the immediate and surface causes. These may include performance weaknesses in the safety management system (SMS) elements.
- Identify the deep root causes: They are the underlying reasons why the contributing factors existed in the first place, and may include SMS design flaws.
Knowledge Check Choose the best answer for the question.
5-3. Which method works best in identifying underlying contributing factors for accidents?
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