Question 1 – Evidence and Timeline

(a) Examine the collected evidence for this incident and present this using the structure of the Swiss Cheese Model.  

(b) You should present the layers of Organisational Influence, Unsafe Supervision, Preconditions and Unsafe Acts independently and highlight your reasons for placing each item within the layer. You should also state where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be overcome (if possible).

(c) For all evidence that you use, you should present actual and/or potential scientific verification, and you should formally cite the source(s).  

(d) From this evidence, create a timeline of events that led up to the collision and the subsequent loss of Lamma IV and the lives. Each element of the timeline should identify the evidences and from which layer of the Swiss Cheese Model these come from.  

(e) You are free to use other additional tools to support your analysis, but if so you should state your reason(s) for doing so.

Question 2 – Root Cause Analysis

(a) From the evidence gathered and your timeline, construct a Root Cause Analysis (RCA) using the Swiss Cheese Model created in Question 1.

(b) Identify the Root Cause(s) of the incident using a Causal Tree.

(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.  

(d) Analyse the likelihood of success for each recommendation, presenting reasoning for this.

(e) You are free to choose the format of the recommendations; however, the format chosen should support the earlier assessment methodologies that you employed.  

Question 3 – Incident Report

(a) Create a detailed report of this incident using the structure studied in this course i.e.

(i) What happened?

(ii) What caused it to happen?

(iii) What you recommend should happen next.