IAEA E-learning Program

Safety and Quality in Radiotherapy

 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTIONS:

9.1 Purpose and principles

9.2 Treatment planning
9.3 Information transfer
9.4 Calibration
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

MODULE OBJECTIVES

1. To introduce and demonstrate fault tree analysis as a safety tool for

radiotherapy.
2. To perform partial fault tree analyses for situations that resemble the
three actual incidents that we have discussed during this e-learning
program.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTIONS:

9.1 Purpose and principles

9.2 Treatment planning
9.3 Information transfer
9.4 Calibration
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

OBJECTIVES

1. To examine the anatomy of a fault tree.

2. To appreciate the relationship between fault tree analysis and failure
modes and effects analysis.
3. To explore the similarities and differences between fault tree analysis
and root cause analysis.
4. To develop a simple demonstration fault tree based on the example
used in module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Approaches to Quality Management

Incident learning systems are used retroactively to analyze incidents that have
occurred or proactively to analyze potential incidents (near misses).

Failure modes and effects analyses (FMEA) and fault tree analyses (FTA) are
(typically) used prospectively to analyze systems for weaknesses.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Whats the purpose of a fault tree analysis?

Fault tree analysis (FTA) is a visual tool that helps us to trace the propagation of an
error from its basic or root cause through to a postulated failure. When developed, an
FTA can help us:
Identify possible systemic program weaknesses.
Place impediments to error propagation such as barriers and checks (QA and QC).
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Where does fault tree analysis fit into a clinical quality management and
patient safety program?

Fault tree analysis (FTA), complements failure modes and effects analysis being a
prospective approach to quality and safety.
It is important to realize that a failure modes and effects analysis (FMEA) does not
and cannot replace learning from incidents.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

OBJECTIVES

1. To examine the anatomy of a fault tree.

2. To appreciate the relationship between fault tree analysis and failure
modes and effects analysis.
3. To explore the similarities and differences between fault tree analysis
and root cause analysis.
4. To develop a simple demonstration fault tree based on the example
used in module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

O Ring
What does a fault tree look like? hardened

Pump fails

Pressure control
system fails Motor burns
out
Pressure release
valve fails

Nuclear
Explosion
Event/situation
/circumstance
Fuel rods stick

Cant retract
fuel rods
OR
Manual retraction
under repair

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

O Ring
What does a fault tree look like? hardened

Pump fails

Pressure control
system fails Motor burns
out
Pressure release
valve fails

Nuclear
Explosion
Event/situation
/circumstance
Fuel rods stick

Cant retract
fuel rods
OR
Manual retraction
under repair

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

O Ring
What does a fault tree look like? hardened

Pump fails

Pressure control
system fails Motor burns
out
Pressure release
valve fails

Nuclear
Explosion
Event/situation
/circumstance
Fuel rods stick

Cant retract
fuel rods
OR
Manual retraction
under repair

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

O Ring
What does a fault tree look like? hardened

Pump fails

Pressure control
system fails Motor burns
out
Pressure release
valve fails

Nuclear
Explosion
Event/situation
/circumstance
Fuel rods stick

Cant retract
fuel rods
OR
Manual retraction
under repair

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Fault Tree Analysis

Fault tree analyses are extensively used in high risk, high reliability industries
such as the chemical, nuclear and aviation industries.
Fault trees can be descriptive or include probabilities for the various failure
pathways. Fault tree analyses are particularly useful for tracing the effects of
equipment failures.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

OBJECTIVES

1. To examine the anatomy of a fault tree.

2. To appreciate the relationship between fault tree analysis and failure
modes and effects analysis.
3. To explore the similarities and differences between fault tree analysis
and root cause analysis.
4. To develop a simple demonstration fault tree based on the example
used in module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Failure Modes and Effects Analysis

This is the final FMEA worksheet we developed in Module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Failure Modes and Effects Analysis

But what do these failure pathways look like. Specifically, where did they start and how can
they be interrupted?
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Failure Modes and Effects Analysis

A fault tree analysis is a detailed description of a failure pathway.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

OBJECTIVES

1. To examine the anatomy of a fault tree.

2. To appreciate the relationship between fault tree analysis and failure
modes and effects analysis.
3. To explore the similarities and differences between fault tree analysis
and root cause analysis.
4. To develop a simple demonstration fault tree based on the example
used in module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Workload
Root Cause Analysis1 pressures
Incomplete
review
Risk
Awareness

Beam not No patient Policy not

verified specific QC followed

Lack of
training
Console screen
Not verified
Lack of risk
awareness
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

O Ring
Fault Tree Analysis2 hardened

Pump fails
Pressure
control system Motor burns
fails out
Pressure
release valve
fails
Nuclear
Explosion

Fuel rods stick

Cant retract
fuel rods
Manual
retraction
under repair
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

FTA in the context of RCA

Look similar?
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

FTA in the context of RCA

A fault tree analysis (FTA) can be regarded as a hypothetical root cause analysis (RCA).

An actual or potential failure starts an RCA.

Postulated failures are used to start an FTA.
However, in both, the failure pathway is traced back to causes/contributory factors.
An RCA uses only (implied) AND gates.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

OBJECTIVES

1. To examine the anatomy of a fault tree.

2. To appreciate the relationship between fault tree analysis and failure
modes and effects analysis.
3. To explore the similarities and differences between fault tree analysis
and root cause analysis.
4. To develop a simple demonstration fault tree based on the example
used in module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Failure Modes and Effects Analysis

As a simple example well develop a fault tree for the failure pathway: Forgot the map.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Calgary Basic Cause Table3

http://www.ihe.ca/publications/library/archived/a-reference-guide-for-learning-from-incidents-in-radiation-treatment/
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Procedure not
A Fault Tree for Forgot the map followed
Map left on
kitchen table Inadequate
Unfamiliar hazard
territory assessment

Spouse took
map from car Communication

Lost
Event/situation
Damaged by /circumstance
vandals
Signposts
inadequate
Bankrupt local
OR
authority

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Change our standard operating procedure Procedure not

followed
Map left on
kitchen table Inadequate
Unfamiliar hazard
territory assessment

Spouse took
map from car Communication

Lost
Event/situation
Damaged by /circumstance
vandals
Signposts
inadequate
Bankrupt local
OR
authority

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Incorporate quality management Procedure not

followed
Map left on
kitchen table Inadequate
Unfamiliar hazard
territory assessment

Spouse took
map from car Communication

QC: Check for map

Lost
before driving off
Event/situation
Damaged by /circumstance
vandals
Signposts
inadequate
Bankrupt local
OR
authority

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

Procedure not
Incorporate quality management followed
Map left on
kitchen table
Inadequate
hazard
Unfamiliar assessment
territory Spouse took
map from car Communication

Fails quality
control: no
Lost map in car
Event/situation
Damaged by /circumstance
vandals
Signposts
inadequate
Bankrupt local
OR
authority

AND
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

TG 100s Key Core Requirements

To prevent failures in radiation therapy in general (and IMRT in particular), a QM
program should have elements that TG 100 terms key core requirements for quality.
These core requirements are:
Standardized procedures
Adequate staff, physical and IT resources
Adequate training of staff
Maintenance of hardware and software resources
Clear lines of communication among staff
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

A few final notes

Basic causes identified in the right most boxes of a fault tree do not, in general, make
failure inevitable.
To be useful, basic causes should be actionable.
Addressing the basic causes identified with a fault tree should reduce the occurrence
value in the accompanying failure modes and effects analysis.
Incorporating quality control into a fault tree should reduce the detectability value in
the accompanying failure modes and effects analysis.
Always be aware that changing processes, including QC, has the potential to
introduce other sources of error.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

SUMMARY

We have:

1. Examined the anatomy of a fault tree.

2. Appreciated the relationship between fault tree analysis and failure

modes and effects analysis.
3. Explored the similarities and differences between fault tree analysis and
root cause analysis.
4. Developed a simple demonstration fault tree based on the example used
in Module 8.1.
 Safety and Quality in Radiotherapy
MODULE 9: FAULT TREE ANALYSIS

SECTION 1: PURPOSE AND PRINCIPLES

REFERENCES AND ADDITIONAL RESOURCES

1. The Ottawa Incident.

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=34948
2. Huq MS, Fraass BA, Dunscombe PB, et al. The report of Task Group 100 of the AAPM:
Application of risk analysis methods to radiation therapy quality management. Medical
Physics 43, 4209 4262. 2016.
3. Cooke DL, Dubetz M, Rahim H, et al. 2006.
http://www.assembly.ab.ca/lao/library/egovdocs/2006/alhfm/153508.pdf