ANALYSIS AND ESTABLISHMENT OF THE ROOT CAUSES OF INCIDENTS WHEN WORKING WITH CRITICAL INFRASTRUCTURE

Abstract

This paper investigates the analysis and determination of the root causes of incidents occurring when dealing with critical infrastructure. Through detailed examination of cause-and-effect factors, including human errors and organizational issues, the paper emphasizes the importance of fully understanding and addressing these causes. Utilizing tools such as the Root Cause Tree®, the paper demonstrates how these incidents can be analyzed down to their most basic causes. For instance, the analysis identified four root causes for a high temperature problem in one incident: the need for improvements in vigilance monitoring, shift planning, choice of a tired worker, and implementation of a "no-sleeping at workplace" policy. The results from this analysis underline the significance of human factors management, specifically in terms of training, procedures, and engineering solutions when dealing with critical infrastructure.