From the evidence gathered and your timeline with the Swiss Cheese Model created in Question 1: Jerald Report

Question 2 — Root Cause Analysis
(a) From the evidence gathered and your timeline with the Swiss Cheese Model created in Question 1, construct a Root Cause Analysis (RCA) for the incident.

(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 conclusions and recommendations to ensure that this incident does not happen again. 5

(d) Analyse the likelihood of success for each recommendation, presenting your rationale 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.

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