Glossary of Data Variables for Fatal and accident causation ... - ERSO

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Manual For SafetyNet accident causation system (SNACS) Choosing a specific genotype means that that particular analysis chain is finished, due to the stop rules. This means that you have reached the end point for that chain, and can move on to another unfinished chain. To remember this, make some kind of marking which indicates that you’ve reached an end point in the linking template you are working with. Looking for a general cause If none of the specific causes available fits with the accident description, then we move on to the general genotypes. These are listed in the far left cell on the table row of the general consequent that you previously located. Here you look at the available genotypes, and you choose one or more that fits with the accident description and your evaluation of the circumstances. If you find one or more general genotypes that fit with the accident description, you write these down on you linking template to the left of the general consequent that they link to (in this example “Observation missed”). Having found one or more general consequents means that the second of the stop rules apply: 2. General genotypes have the status of non-terminal events. If a general genotype is the most likely cause of a general consequent, that cause is chosen and the analysis must continue. This means that you repeat step two for each of the chosen genotypes, until either stop rule 1, 3 or 4 is fulfilled. If you on the other hand do not find a general phenotype that fits with the accident description, then this can be due to two possibilities: a) either there are no genotypes specified as general or specific causes for the general consequent you have chosen, or b) none of the available genotypes fits with the accident description. This possibility a) falls under stop rule 3: 3. If there exists no general or specific genotypes that links to the chosen consequent, the analysis stops. Possibility b) falls under stop rule 4: 4. If none of the available genotypes for the chosen consequent is relevant, given the information available about the accident, the analysis stops. Should stop rule 3 or 4 be fulfilled, then you have reached the end point for that analysis chain, and you move on to other unfinished chains of analysis. When any stop rules 1, 3 or 4 have been fulfilled for all chains of analysis, the analysis is finished or complete. This does not necessarily mean that we have succeeded in systematically explaining completely why the accident happened; it just means that we have categorised and sorted out everything we know about the accident in as good a way as possible. When the analysis is finished and you register the links into the database, please remember to register each of the chains separately, even though they Page 150 of 215
Manual For SafetyNet accident causation system (SNACS) may share intermediate links (see section 6.3 - Multiple chains of analysis above for the reasons why this is necessary). Remember that you do not have to be 100 % sure that every chain is correct in detail, because the database allows you to grade your confidence in each chain of analysis, through the explanation fields. If something is possible but not very sure, then put it in anyway and just be sure to mark that your confidence in this particular chain is not very high. Page 151 of 215
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