1. What are the challenges of the cause tree?

When an incident or accident occurs, the first instinct is to find someone to blame. But without a thorough investigation, the accident is likely to happen again.

This is why an analysis of the event, after the fact, is essential to your system improvement approach.

First of all, it's important to remember that an accident is never due to chance or fate. The causes are often multiple, covering everything from people, equipment and products to company organization.

The aim of the analysis is therefore not to find one or more culprits, but to trace the causes of the incident or accident back to its origin; the objective is therefore to identify the circumstances that led to the undesired event, in order to put in place measures to prevent the event from happening again.

Here are a few definitions:...