Quantcast Figure  4-4.—Sample  fault  tree  diagram

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Page Title: Figure 4-4.—Sample fault tree diagram
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Reconstructing  the  Mishap
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Summary - 14167_73
Figure  4-4.—Sample  fault  tree  diagram. symbolic diagram on paper showing “what if ”problems (fig. 4-4). It also branches off into other components affected by the failure. Analyzing mishap investigation information  works  backwards  from  the  final  failure  to the  original  component.  It  shows  the  cause-and-effect relationship  of  systems. CHANGE ANALYSIS.— Change  signals  trouble. A change in the steering of the ship or a change in the sound of an engine may signal trouble. Departures from the norm may be an element in the chain of events leading to a mishap. Changes interact with subsequent changes. A change in a Maintenance Requirement Card (MRC)  could  cause  a  change  in  frequency  of  the maintenance. The change in frequency could change the adequacy of the maintenance. The change in adequacy of  maintenance  could  change  the  reliability  of  the equipment. The change in reliability could lead to a mishap. Analyzing the changes that affected a system or procedure may provide mishap causes. In a change analysis, we compare a mishap situation with a similar but mishap-free situation. We determine the differences 4-16

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