In science and engineering, root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. It is widely used in IT operations, manufacturing, telecommunications, industrial process control, accident analysis (e.g., in aviation, rail transport, or nuclear plants), medical diagnosis, the healthcare industry (e.g., for epidemiology), etc. Root cause analysis is a form of inductive inference (first create a theory, or root, based on empirical evidence, or causes) and deductive inference (test the theory, i.e., the underlying causal mechanisms, with empirical data).
In aviation, a controlled flight into terrain is an accident in which an airworthy aircraft, fully under pilot control, is unintentionally flown into the ground, a body of water or other obstacle. In a typical CFIT scenario, the crew is unaware of the impending collision until impact, or it is too late to avert. The term was coined by engineers at Boeing in the late 1970s.
A train accident or train wreck is a type of disaster involving two or more trains. Train wrecks often occur as a result of miscommunication, as when a moving train meets another train on the same track, when the wheels of train come off the track or when a boiler explosion occurs. Train accidents have often been widely covered in popular media and in folklore.
In the field of human factors and ergonomics, human reliability is the probability that a human performs a task to a sufficient standard. Reliability of humans can be affected by many factors such as age, physical health, mental state, attitude, emotions, personal propensity for certain mistakes, and cognitive biases.
In aviation, pilot error generally refers to an action or decision made by a pilot that is a substantial contributing factor leading to an aviation accident. It also includes a pilot's failure to make a correct decision or take proper action. Errors are intentional actions that fail to achieve their intended outcomes. The Chicago Convention defines the term "accident" as "an occurrence associated with the operation of an aircraft [...] in which [...] a person is fatally or seriously injured [...] except when the injuries are [...] inflicted by other persons." Hence the definition of "pilot error" does not include deliberate crashing.
Accident analysis is a process carried out in order to determine the cause or causes of an accident so as to prevent further accidents of a similar kind. It is part of accident investigation or incident investigation. These analyses may be performed by a range of experts, including forensic scientists, forensic engineers or health and safety advisers. Accident investigators, particularly those in the aircraft industry, are colloquially known as "tin-kickers". Health and safety and patient safety professionals prefer using the term "incident" in place of the term "accident". Its retrospective nature means that accident analysis is primarily an exercise of directed explanation; conducted using the theories or methods the analyst has to hand, which directs the way in which the events, aspects, or features of accident phenomena are highlighted and explained. These analyses are also invaluable in determining ways to prevent future incidents from occurring. They provide good insight by determining root causes, into what failures occurred that led to the incident.
The Swiss cheese model of accident causation is a model used in risk analysis and risk management. It likens human systems to multiple slices of Swiss cheese, which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure.
The system safety concept calls for a risk management strategy based on identification, analysis of hazards and application of remedial controls using a systems-based approach. This is different from traditional safety strategies which rely on control of conditions and causes of an accident based either on the epidemiological analysis or as a result of investigation of individual past accidents. The concept of system safety is useful in demonstrating adequacy of technologies when difficulties are faced with probabilistic risk analysis. The underlying principle is one of synergy: a whole is more than sum of its parts. Systems-based approach to safety requires the application of scientific, technical and managerial skills to hazard identification, hazard analysis, and elimination, control, or management of hazards throughout the life-cycle of a system, program, project or an activity or a product. "Hazop" is one of several techniques available for identification of hazards.
The Fire Fighter Near Miss Reporting System was launched on August 12, 2005 by the International Association of Fire Chiefs. It was announced at a press conference in Denver, Colorado, after having completed a pilot program involving 38 fire departments across the country. The Near Miss Reporting System aims to prevent injuries and save lives of other firefighters by collecting, sharing and analyzing near-miss experiences. The near-miss experiences are collected by firefighters who voluntarily submit them; the reports are confidential, non-punitive, and secure. After the reports are compiled, they are posted to the website where firefighters can access them and learn from each other's real-life experiences. Overall these reports help to formulate strategies, reduce firefighter injuries and fatalities, and enhance the safety culture of the fire service. The program is based on the Aviation Safety Reporting System (ASRS), which has been gathering reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The reporting system is funded by the International Association of Fire Chiefs.
The Human Factors Analysis and Classification System (HFACS) identifies the human causes of an accident and offers tools for analysis as a way to plan preventive training. It was developed by Dr. Scott Shappell of the Civil Aviation Medical Institute and Dr. Doug Wiegmann of the University of Illinois at Urbana-Campaign in response to a trend that showed some form of human error was a primary causal factor in 80% of all flight accidents in the Navy and Marine Corps.
The Technique for human error-rate prediction (THERP) is a technique that is used in the field of Human Reliability Assessment (HRA) to evaluate the probability of human error occurring throughout the completion of a task. From such an analysis, some corrective measures could be taken to reduce the likelihood of errors occurring within a system. The overall goal of THERP is to apply and document probabilistic methodological analyses to increase safety during a given process. THERP is used in fields such as error identification, error quantification and error reduction.
A Technique for Human Event Analysis (ATHEANA) is a technique used in the field of human reliability assessment (HRA). The purpose of ATHEANA is to evaluate the probability of human error while performing a specific task. From such analyses, preventative measures can then be taken to reduce human errors within a system and therefore lead to improvements in the overall level of safety.
In computer security, a threat is a potential negative action or event enabled by a vulnerability that results in an unwanted impact to a computer system or application.
In aeronautics, loss of control (LOC) is the unintended departure of an aircraft from controlled flight and is a significant factor in several aviation accidents worldwide. In 2015 it was the leading cause of general aviation accidents. Loss of control may be the result of mechanical failure, external disturbances, aircraft upset conditions, or inappropriate crew actions or responses.
Human factors are the physical or cognitive properties of individuals, or social behavior which is specific to humans, and which influence functioning of technological systems as well as human-environment equilibria. The safety of underwater diving operations can be improved by reducing the frequency of human error and the consequences when it does occur. Human error can be defined as an individual's deviation from acceptable or desirable practice which culminates in undesirable or unexpected results. Human factors include both the non-technical skills that enhance safety and the non-technical factors that contribute to undesirable incidents that put the diver at risk.
[Safety is] An active, adaptive process which involves making sense of the task in the context of the environment to successfully achieve explicit and implied goals, with the expectation that no harm or damage will occur. – G. Lock, 2022
Dive safety is primarily a function of four factors: the environment, equipment, individual diver performance and dive team performance. The water is a harsh and alien environment which can impose severe physical and psychological stress on a diver. The remaining factors must be controlled and coordinated so the diver can overcome the stresses imposed by the underwater environment and work safely. Diving equipment is crucial because it provides life support to the diver, but the majority of dive accidents are caused by individual diver panic and an associated degradation of the individual diver's performance. – M.A. Blumenberg, 1996
The AcciMap approach is a systems-based technique for accident analysis, specifically for analysing the causes of accidents and incidents that occur in complex sociotechnical systems.
In aviation safety, threat and error management (TEM) is an overarching safety management approach that assumes that pilots will naturally make mistakes and encounter risky situations during flight operations. Rather than try to avoid these threats and errors, its primary focus is on teaching pilots to manage these issues so they do not impair safety. Its goal is to maintain safety margins by training pilots and flight crews to detect and respond to events that are likely to cause damage (threats) as well as mistakes that are most likely to be made (errors) during flight operations.
Aviation accident analysis is performed to determine the cause of errors once an accident has happened. In the modern aviation industry, it is also used to analyze a database of past accidents in order to prevent an accident from happening. Many models have been used not only for the accident investigation but also for educational purpose.
In aviation, the SHELL model is a conceptual model of human factors that helps to clarify the location and cause of human error within an aviation environment.
Investigation of diving accidents includes investigations into the causes of reportable incidents in professional diving and recreational diving accidents, usually when there is a fatality or litigation for gross negligence.
