LATENT
FAILURE
PRE
CONDITION
ACTIVE
FAILURE
Barrier
Figure
Beta diagram
diagram
Figure 2:
2: Tripod
Tripod Beta
Inadequate risk assessment
Issued based
Baseline
Con8nuous
Lack of control
Inadequate of system, standard and compliance
Root causes
Personal factors
Job factors
Immediate cause
Substandard acts
Substandard condi8on
Incident
Loss producing event
Harm
Loss
Damage
Liability
Figure Figure
3: Root
Cause
Analysis
technique
3: Root
Cause
Analysis
technique method
57