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Whenever significant changes are planned in operations in which there is significant operational risk of
any kind. An example is the decision to conduct a certain type of operation at night that has heretofore
only been done in daylight.
Periodically in any important operation, to detect the occurrence of unplanned changes.
As an accident investigation tool.
As the only hazard identification tool required when an operational area has been subjected to in-depth
hazard analysis, the Change Analysis will reveal whether any elements exist in the current operations that
were not considered in the previous in-depth analysis.
METHOD: The Change Analysis is best accomplished using a format such as the sample worksheet
shown at Figure 1.1.6B. The factors in the column on the left side of this tool are intended as a
comprehensive change checklist.
FAA System Safety Handbook, Appendix F
December 30, 2000
F-17
Figure 1.1.6B Sample Change Analysis Worksheet
Target: ________________________________ Date: ______________________
FACTORS EVALUATED
SITUATION
COMPARABLE
SITUATION
DIFFERENCE SIGNIFICANCE
WHAT
Objects
Energy
Defects
Protective
Devices
WHERE
On the object
In the process
Place
WHEN
In time
In the process
WHO
Operator
Fellow worker
Supervisor
Others
TASK
Goal
Procedure
Quality
WORKING
CONDITIONS
Environmental
Overtime
Schedule
Delays
TRIGGER
EVENT
MANAGERIAL
CONTROLS
Control Chain
Hazard Analysis
Monitoring
Risk Review
To use the worksheet: The user starts at the top of the column and considers the current situation compared
to a previous situation and identifies any change in any of the factors.
When used in an accident investigation, the accident situation is compared to a previous baseline.
The significance of detected changes can be evaluated intuitively or they can be subjected to "What If",
Logic Diagram, or scenario, other specialized analyses.
FAA System Safety Handbook, Appendix F
December 30, 2000
F-18
RESOURCES: Experienced operational personnel are a key resource for the Change Analysis tool.
Those who have long-term involvement in an operational process must help define the “comparable
situation.” Another important resource is the documentation of process flows and task analyses. Large
numbers of such analyses have been completed in recent years in connection with quality improvement
and reengineering projects. These materials are excellent definitions of the baseline against which change
can be evaluated.
COMMENTS: In organizations with mature ORM processes, most, if not all, higher risk activities will
have been subjected to thorough ORM applications and the resulting risk controls will have been
incorporated into operational guidance. In these situations, the majority of day-to-day ORM activity will
be the application of Change Analysis to determine if the operation has any unique aspects that have not
been previously analyzed.
1.1.7 THE CAUSE AND EFFECT TOOL
FORMAL NAME: The Cause and Effect Tool
ALTERNATIVE NAMES: The cause and effect diagram. The fishbone tool, the Ishikawa Diagram
PURPOSE: The Cause and Effect Tool is a variation of the Logic Tree tool and is used in the same
hazard identification role as the general Logic Diagram. The particular advantage of the Cause and Effect
Tool is its origin in the quality management process and the thousands of personnel who have been
trained in the tool. Because it is widely used, thousands of personnel are familiar with it and therefore
require little training to apply it to the problem of detecting risk.
APPLICATION: The Cause and Effect Tool will be effective in organizations that have had some
success with the quality initiative. It should be used in the same manner as the Logic Diagram and can be
applied in both a positive and negative variation.
METHOD: The Cause And Effect diagram is a Logic Diagram with a significant variation. It provides
more structure than the Logic Diagram through the branches that give it one of its alternate names, the
fishbone diagram. The user can tailor the basic “bones” based upon special characteristics of the
operation being analyzed. Either a positive or negative outcome block is designated at the right side of the
diagram. Using the structure of the diagram, the user completes the diagram by adding causal factors in
either the “M” or “P” structure. Using branches off the basic entries, additional hazards can be added.
The Cause And Effect diagram should be used in a team setting whenever possible.
　
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