Events and causal factors charting

Abstract

The Events and Causal Factors (E and CF) chart (or diagram) depicts in logical sequence the necessary and sufficient events and causal factors for accident occurrence. It can be used not only to analyze the accident and evaluate the evidence during investigation, but also can help validate the accuracy of preaccident systems analyses. The E and CF sequence charting technique is an integral and important part of the MORT-based DOE accident investigation process. It is used in conjunction with other key MORT tools, such as MORT tree analysis, change analysis, and energy trace and barrier analysis, to achieve optimum results in accident investigation. E and CF charting has been used successfully as a focal point of analysis on several ERDA and DOE accident and incident investigations with excellent results. The fundamentals of this valuable MORT tool are discussed in this monograph. 9 references.

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