ABSTRACT
Accidents are rarely simple and almost never result from a single cause. They may develop from a sequence of events involving performance errors, changes in procedures, oversights, and omissions. Events and conditions must be identi€ed and examined in order to €nd the cause of the accident and a way to prevent that accident and similar accidents from recurring. To prevent the recurrence of accidents, one must identify the accident’s causal factors. The higher the level in the management and oversight chain in which the root cause is found, the more diffused the problem can be.
