Production Factors are the active failures (unsafe acts or decisions) that occur during an operation or as a part of the operation that result from one or more of the preceding LUCs and lead to the initiating event. Experienced marine investigators will often encounter situations in which a person's precondition, such as fatigue, appears to have caused a casualty, yet the same person successfully accomplished the same task the day before (or the hour before) with the same precondition. What was different about the task at the time of the incident? The answer lies in the relationship between preconditions and active failures. It is almost impossible to predict exactly when, where, and how a given precondition will manifest itself as an active failure. It is difficult to say-when a fatigued person will make a bad decision; all that can be said with certainty is that given enough opportunities (decisions), one will be bad because of the fatigue. Examples of Production Factor active failures include omission of steps in a task, use of the wrong procedures, violations of law or regulation, and bad decisions in the presence of a hazard.

　

Production Factor active failures are discussed in detail in Enclosure 3. (Human Error Analysis).

　

Very few Production Factor active failures result in actual damage or injury, even when the system is relatively undefended. In a grounding scenario, for instance, a pilot's decision to initiate a turn too early.(an active failure) does not in itself cause any unwanted outcome. Instead, the active failure must be left undetected and uncorrected in order to progress into the grounding. In other words, the system's defenses against a grounding must be missing (an LUC) or inadequate (an active failure). Examples of Defense Factor active failures and LUCs include failed protective gear, disabled warning systems, absence of monitoring (or plotting of fixes), safety regulations not enforced, and over-reliance on automation.

　

Defense Factor active failures and LUCs commonly found in system incidents include:

Defenses that were present but inadequate

Defenses that were present but deliberately disabled

Defenses that were never present or once present but now removed

Defenses that do not exist or are unreasonable

Automation/Software Failures (same as Enclosure 3 terms)

Human Errors (See Enclosure 3)

One of the most difficult aspects of any investigation is identifying exactly which aspects of an incident you are trying to explain. For the purposes of analyzing the causes of an incident, marine investigators must carefully identify the Initiating Event. While a variety of actions, events, and conditions will precede an incident, a point must be chosen at which the incident is considered to start. The marine investigator will initially focus on explaining how the incident began, and will then turn to explaining how the incident progressed. For the purposes of analyzing the causes of an incident, the Initiating Event is simply the first unwanted or negative outcome in the timeline (see events list of timeline from Enclosure 1). In marine casualties and pollution incidents the Initiating Event is usually NOT the first "reportable" event. In most cases, the reportable event follows the Initiating Event and (when explained) sheds more light on the causes of the incident Subsequent events are then identified.

　

When the previous step has been completed, the marine investigator will have identified the Initiating Event. To explain how the incident progressed from the Initiating Event into all the subsequent events, the marine investigator must identify the defensive faults that connect one event into another. In most circumstances, the defenses on a vessel or platform defend against contingencies arising AFTER the Initiating Event. Upon completion of this step the Human Error Analysis should be conducted (see Enclosure 3).

　

In the simplest sense, production is the maritime operation that was going on at the time of the incident. Once the marine investigator has identified the Initiating Event, he or she should ask what operation was going on at the time and just previous. The next common sense question is which people (liveware) were conducting the operation and what software was involved in the operation (if applicable, as in automation). In any incident, a person will have made a mistake or will have willfully violated a standard/regulation/procedure or automation will have failed. The marine investigator should identify the mistake(s), violation(s) and automation failure(s) occurring in production. They must be careful not to confuse production activities (such as navigating) with defensive activities (such as plotting fixes). As a rule of thumb, active failures in production have an immediate and recognizable effect on safety.

　

While analyzing the information discovered during fact-finding, marine investigators may discover several production active failures (as well as several preconditions, LUCs in the workplace or organization). While each is worthy of attention because they must be eliminated, not all of them necessarily connect to the incident at hand. Marine investigators shall identify those active failures and LUCs with causal connection to the incident. Other active failures (particularly willful violations) and LUCs may also be noted (and should be if severe enough).

　

Once the marine investigator has completed the previous steps, they have (essentially) explained why the production active failure has occurred. Such active failures, however, occur constantly in complex systems. Relatively few, however, result in incidents. When a system's defenses were sufficient to detect an active failure and prevent the incident, a "near miss" is said to have occurred (though "near hit" may be the more appropriate term). In order to explain an incident, marine investigators must identify the active failure or LUCs in defenses. Many faults may be discovered in the system's defenses, only some of which will be causally connected to the production active failure and the incident.

　

Once the marine investigator has identified the exact failure in production, they must ask "What condition did the person/automation have to be in for them/it to fail?" Preconditions create the potential for a wide variety of software and human (liveware) active failures. Marine investigators should again remember that they may encounter a large number of latent unsafe (pre)conditions. A given mariner may, for instance, have had LUCs of fatigue, drug use, and an aggressive attitude. In this case, it may be difficult to ascertain exactly which precondition has a causal connection to the production active failure. Marine investigators should record all preconditions internal to a person as having a causal connection. Similarly, they may be tempted to "weigh" a given precondition over another (fatigue was more important than drug use or attitude, for instance). Marine investigators should not give opinions as to the relative strength of various preconditions in their causal connection to a given production active failure without significant scientific basis for those opinions.

　

Once the preconditions of equipment (hardware), people (liveware), and software have been determined, the marine investigator should identify the condition the management environment must have been in to create the preconditions. Marine investigators should also be careful to consider the absence of (any) management in addition to pro-active (but poor) management. Marine investigators are cautioned to remember that line managers' ability to manage is limited by the size of their departmental budgets or the resources at their disposal. For this reason, it is important to carefully recognize the causal connection of Organizational Factors when identifying Workplace Factors.

　

The basic idea underlying the causal analysis system (and the IMO documents upon which it is based) is that system incidents have their primary origins in fallible decisions made by designers and high-level decision makers. Marine investigators, having identified workplace LUCs, should identify the conditions line managers were responding to. Decision makers' fallible decisions create LUCs that affect line managers. Marine investigators should bear in mind that decision makers rarely have direct access to the consequences of their decisions, and may be almost entirely unaware of the LUCs they have created.