1. WHAT IF ANALYSIS USED TO IDENTIFY HAZARDS HAZARDOUS EVENTS
CAN INCLUDE PEOPLE AND/OR EQUIPMENT
SUGGESTED METHOD UNDER OSHA’S PSM

2. WHAT IF MEMBERS ASSEMBLE A TEAM OF “EXPERTS” INCLUDE:
PRODUCTION
SAFETY
ENGINEERING
THE MORE DIVERSE, THE BETTER

3. WHAT IF PROCESS MAP OUT THE PROCESS IDENTIFY EQUIPMENT TASKS
PROCESS CONTROL MEASURES

4. COMPLETING THE WHAT IF ANALYSIS
EXAMINE EACH STEP
DETERMINE PEOPLE, EQUIPMENT, INTERFACES
ASK “WHAT IF?”
DETERMINE ACCIDENT SCENARIOS IN WHICH THE EVENT COULD OCCUR AND CONTROL MEASURES

5. WHAT IF ANALYSIS FRAMEWORK
CONSEQUENCES
PROTECTION

6. CRITICAL INCIDENT TECHNIQUE
USED BY FITTS AND JONES DURING WORLD WAR II
AIR CORP PILOTS
ERRORS READING DISPLAYS AND OPERATING AIRCRAFT

7. CRITICAL INCIDENT TECHNIQUE
PREVENT FAILINGS TO BE CARRIED OVER
ANALYZE PREVIOUS SYSTEM PROBLEMS
EXAMINES SITUATIONS THAT COULD HAVE RESULTED IN A LOSS

8. CRITICAL INCIDENT TECHNIQUE
USES QUALITATIVE INFORMATION
INTERVIEW PERSONS INVOLVED
OPERATIONALLY EXPERIENCED PERSONNEL

9. SITUATIONS TO EXAMINE
HAZARDS
NEAR MISSES
UNSAFE CONDITIONS

10. INTERVIEW PROCESS SELECT SAMPLE OF SUBJECTS
HAVE USED THE SYSTEM BEFORE
INCLUDE THEIR OWN EXPERIENCES
EXPERIENCES OF OTHERS THAT THEY HAVE OBSERVED
DESCRIBE ALL MISHAPS AND OCCURRENCES

11. OUTCOMES SAME AS AN ACCIDENT INVESTIGATION
IDENTIFICATION OF A HAZARD THROUGH PERSONAL INVOLVEMENT
DEVELOP RECOMMENDATIONS FOR IMPROVEMENT

12. CONDUCTING A CRITICAL INCIDENT TECHNIQUE
SELECT A GROUP WITH PRIOR EXPERIENCE WITH A SYSTEM
INFORM SUBJECTS OF THE PURPOSE OF THE STUDY
DESCRIBE ALL INCIDENTS THEY COULD RECALL

13. CONDUCTING A CRITICAL INCIDENT TECHNIQUE
PROVIDE A LIST OF INCIDENTS THAT HAD OCCURRED
ASK TO RECALL IF ANY HAD HAPPENED TO THEM

14. Fault Tree Analysis
Fault tree analysis was developed in 1962 for the U.S. Air Force by Bell Telephone Laboratories for use with the Minuteman system
Was later adopted and extensively applied by the Boeing Company
Is one of many symbolic logic analytical techniques found in the operations research discipline.

15. Outcomes of FTA
Graphic display of chains of events/conditions leading to the loss event.
Identification of those potential contributors to failure that are “critical.”
Improved understanding of system characteristics.
Qualitative/quantitative insight into probability of the loss event selected for analysis.
Identification of resources committed to preventing failure.
Guidance for redeploying resources to optimize control of risk.
Documentation of analytical results.

16. FTA Process A fault tree is a topdown,
logic-driven technique for postulating all possible causes of an event.
The team begins with the
top level event and develops possible causes for that event.
Each of those causes is, in turn, treated as an event for which causes are proposed.
The tree development continues in this manner until a root cause or basic event is reached for which there is no further development within the scope of the investigation.
Once the tree is constructed, the team analyzes the branches of the tree and rules out (marks as false) any branches that are contradictory to the available evidence.

17. Steps in FTA Identify undesirable TOP event
Link contributors to TOP by logic gate
Identify first-level contributors
Link second-level contributors to TOP by logic gates
Identify second-level contributors
Repeat/continue

18. Fault Tree Development
Constructing the logic
Spotting/correcting some common errors
Adding quantitative data

19. Symbols Basic Event–Initiating fault/failure, not developed further.
The Basic Event marks the limit of resolution of the analysis.
TOP Event–foreseeable, undesirable event, toward which all fault tree logic paths flow, or Intermediate event–describing a system state produced by antecedent events.
“Or” Gate–produces output if any input exists. Any input, individual, must be(1) necessary and (2) sufficient to cause the output event.
“And” Gate–produces output if all inputs co-exist.
All inputs, individually must be (1) necessary and (2) sufficient to cause the output event
Most Fault Tree Analyses can be carried out using only these four symbols.

20. Barrier Analysis Systems technique used to evaluate unwanted events
Examines the events and the presence, absence, adequacy of barriers
Barrier Analysis is part of the MORT process (Management Oversight Risk Tree)

21. Barriers Barriers can be physical or administrative
Defined as material, functional, symbolic, and immaterial barrier systems
They can also be defined as “Protecting” (After the event) or “Preventing” (Before the event)

22. Barriers
Material barriers physically prevent an action from being carried out or the consequences from spreading.
Functional (active or dynamic) barriers work by impeding the action to be carried out. A lock, for instance, is a functional barrier, whether it is a physical lock that requires the use of a key.

23. Barriers
Symbolic barriers require an act of interpretation in order to achieve their purpose. All kinds of signs and signals are symbolic barriers
Immaterial barriers are not physically present or represented in the situation, but depend on the knowledge of the user to achieve their purpose. Typical immaterial barriers are: rules, guidelines, restrictions, and laws.

24. Barriers and Hazard Sources
Barriers can be matched with the potential hazard(s)
Page 2-11 in the document link in the module provides a matrix of example hazard sources and typical barriers.
The color coding indicates the degree of barrier effectiveness

26. Barrier Analysis Results
A typical barrier analysis includes the following:
Risk Assessment if done before the fact
Identify Hazard Sources
Identify Paths
Identify Targets
Identify barriers
Assess current barriers in terms of adequacy
If inadequate, develop recommendations for additional/different barriers
Reassess risk levels with recommended changes to barriers