Incident Investigation Blog Series – Part 2: Methodologies and ...

An investigation methodology is how you think about, understand and resolve root causes of an incident. While software can support the ... May24,2019 IncidentInvestigationBlogSeries –Part2:MethodologiesandModels Writtenby:EHSInsightResources Aninvestigationmethodologyishowyouthinkabout,understandandresolverootcausesofanincident.Whilesoftwarecansupporttheprocess,therightmethodologymustfirstbeselectedandimplemented. Theincidentsweinvestigate—accidentsandnearmisses—almostneverresultfromonecause.Mostoftheminvolvemultiple,interrelatedcausalfactors.Thiscomplexityshouldalsobereflectedintheinvestigationmethodologyused.Selectingtherightoneforyoursituationcanbechallenging. Beforewediveintosomeexamplemethodologies,let’slookatsomeanalyticalmodels.ThiswillhelpusthinkaboutsomeofthementionedmethodologiessuchasSystematicCauseAnalysisTechnique,ManagementOversightandRiskTree,andSequentialTimedEventsPlotting. Systemicmodelsfocusonthesystemsandprocessesoftheorganizationalcultureandleadershiptounderstandaccidentcausesasmismatchesorfailuresbetweenthosecomponents. Logicaltreemodelsattempttoanalyzethecausesofaccidentsasasetofeventsandconditions,payingparticularattentiontothelogicalrelationshipsbetweenthem. Sequence-of-Events(Domino,orCausal-sequence)modelsevaluateaccidentsasacontinuoussetoffailuresthatsetoffachainreaction. Epidemiologicalmodels,fromthemedicaltermforthespreadofdisease,investigateaccidentsasemanatingfromhiddenfailuresacrossallorganizationalcomponents,includingmanagement,procedureanddesign. Energymodel,rootedinepidemiology,focusesonthetransferofenergycausinginjurytoaperson,andthereforeseekstofindwaystopreventsuchatransfer. Processmodelsfocusonwaysinwhichaproductionsystemcandeteriorateovertime,makingacleardistinctionbetweenasequenceofeventsandanyunderlyingcausalorcontributingfactors. Humaninformation-processingmodelsanalyzethesituationfromtheperspectiveofahumanoperatorandhisinteractionwithhisenvironment. EHSmanagementmodelsexplorethepossiblecontributingandcausalfactorsrelatedtothefailingsoftheorganizationanditsmanagement. We’llintroduceatleastonemethodologyasanexampleofeachoftheanalyticalmodelswejustlisted.Thesemodelshelpusunderstandhowaparticularmethodologycouldbeusedtoidentifythedirectcausesandcontributingfactorsofincidents.Theycanbeusedtoevaluateandultimatelyreducethenumberofdirectcausestowhichfurtheranalysiswillbeapplied. Thebestmethodologieshelpinvestigatorsbyutilizingmultiplemodelsofanalysistoensurethoroughresearchintorootcausesandcontributorycauses. Someofthemethodologiesdiscussedcouldbedescribedasdiagrammingtechniques.Thesecanprovideausefulframeworkfordevelopingevidencebysummarizingtheeventsinadiagram,whichprovidesaframeworkfordocumentingevidence,identifyingcausalfactors,andidentifyinggapsinknowledge. Diagramshelppreventinaccurateconclusionsbyexposinggapsinthelogicalsequenceofevents.Wheregapsareidentified,furtheranalysiscanuncovernecessarydetail.Thebestmethodologyforyoumightbeacombinationofseveraltoolsormethodologies.Someofthosecovered belowarereallyacombinationoftoolsandtechniquesthatareassembledtogethertoformanewmethodology.Nothingpreventsyoufromdoingthesamethingtomakeanidealmethodologyforyourorganization. SystematicCauseAnalysisTechnique(SCAT) TheInternationalLossControlInstitute(ILCI)developedSCATabout20yearsagoforthepurposeofoccupationalhealthandsafetyincidentinvestigations. SCATisasystemicModelfocusedonthesystemsandprocessesoftheorganizationalcultureandleadership,andisbasedonrootcauseanalysismethods1.Thismethodologyprovidesachartwithaseriesofcrossreferencedcategories.Theinvestigatormustidentifytherelevantfactorsbyworkingsystematicallythroughthechartandidentifyingthecontributingfactorswithineachcategory. Issueswhichleadtoanincidentaredescribedaspointsatwhichtheorganizationlosescontroloverdeficiencies,whichinturnledtotheundesiredoutcome.Inotherwords,SCATasksinvestigatorstogobackbeforethecauseoftheproblemtowheretherootsofthatcausewereformed.Onecausemightbeinadequateleadership,forexample. ManagementOversightandRiskTree(MORT) TheManagementOversightandRiskTree(MORT)isananalyticalprocedurefordeterminingcausesandcontributingfactors.Itarosefromaprojectundertakeninthe1970stoprovidetheU.S.Nuclearindustrywithariskmanagementprogramcompetenttoachievehighstandardsofhealthandsafety2. MORT,alogicaltreemodel,isbasedonFaultTreeAnalysis(FTA),atopdown,deductivefailureanalysisprocedureusedtoanalyzecausesandrelatedfactorsofanundesiredstateusingBooleanlogictocombineaseriesoflower-leveleventsandprecursors. Faulttreeanalysismapstherelationshipbetweenfaults,subsystems,components,andcontrolsbycreatingalogicdiagramoftheoverallsystem.Everysufficientlycomplexsystemissubjecttofailureasaresultofoneormoreindividualcomponentsfailing. MORTusesacomprehensiveanalyticalprocedurethatprovidesadisciplinedmethodfordeterminingthecausesandcontributingfactorsofmajoraccidents.Themethodcanalsobeusedtoproactivelyevaluatethequalityofanexistingsystem.Accidentsaredefinedasunplannedeventsthatproducelosseswhenaharmfulagentcomesintocontactwithapersonorasset.Thiscontactcanoccurbecauseofafailureofpreventionorasanunfortunate,butacceptable,outcomeofariskthathasbeenproperlyassessedandassumed.Mostoftheeffortisdirectedatidentifyingproblemsinthecontrolofaworkprocessanddeficienciesinthebarriersinvolved,asin: Avulnerabletargetexposedto... anagentofharminthe... absenceofadequatebarriers TheMORTmethodologyisless-usedtodayinwhole,butthechartingtechniqueisfairlycommon. SequentialTimedEventsPlotting(STEP) AtechniquethatcanbeusedtodepictabasictimelineofanincidentistheSequentialTimedEventPlot3 alsoknownasaSTEPdiagram.Events,activities,andstatechangescanbeorganizedintoasinglediagraminasequence-of-eventsanalyticalmodel. Thetimelinecanfocusprimarilyon‘what’happened(theevents)andlessonwhythingshappened(thecauses).Thisisbecausetheremaybemultiple(interacting)causesforanyeventonthetimelineandcausesmaynotbeclosetogetherintimeorplace. Whileothermethodologiesmaybemorehelpfultoidentifytherootcausesofaccidentconsequences,STEPcanbeextremelybeneficialforunderstandingtheinteractionbetweenmultiplefactorsandoutcomes.Thetimeline-basedapproachclearlyandconciselygivesapictureofthe‘what’and‘when’toallowinvestigationteamstoworkbackwardstothe‘why’andthe‘how’. STEPisamultilinearsystemsapproachthatviewaccidentsasmultipleavenuesofcausalfactorsthatareinterrelatedandinteractwithotherfactorsthroughoutthesystemtoultimatelyleadtoanaccident. TheSTEPprocedurereliesonaworksheetthatprovidesstructure,visibility,andorganizationtodatagatheringandanalysis.Itgraphicallyrepresentsthebeginningandendofanaccidentsequence,detailingactorsandactionsovertime.Theprocedureaccommodateseventsthatoccurredatthesametime.Theseeventsallowinvestigatorstovisuallyrecreatethementalmapofasequenceofeventsanddeterminegaps. InClosing  ThesearejustsomeoftheincidentinvestigationmodelsandmethodologiesthatcanhelpimproveyourEHSprogram. Decadesofresearchhaveprovidedanumerousmodelsandmethodologiestochoosefrom.Incidentinvestigatorshavesuchawidearrayoftoolsavailable,itcanbechallengingtofindtherightones.Wehopethishelpsencouragethemtoexplorenewapproaches. Althoughwe’veonlyprovidedsomeexamplesofthedifferentmethodologies,therearemanymoretoresearchandevaluate.Whendesigningorselectingamethodology,itiswisetoresearchandevaluateseveral. SCAT:SystematicCauseAnalysisTechnique.Loganville,GA:InternationalLossControlInstitute,1990 Johnson,WilliamG.MORT:SafetyAssuranceSystems,MarcelDekker,Inc.NewYork.1980. Hendrick,Kingsley,andLudwigBenner.InvestigatingAccidentswithSTEP.NewYork:M.Dekker,1987. RelatedResources: IncidentInvestigationBlogSeries –Part1:TheNeedforaMethodology 8InvestigationMethodologiestoUncoverRootCauses   Tag(s): PerformanceImprovement , WorkplaceHealthandSafety , RiskManagement , EHSManagement , IncidentManagement EHSInsightResources Since2009,theteamatEHSInsighthavebeenonamissiontomaketheworldabetterplace.JoinusbysubscribingtoourBlogandreceiveupdatesonwhat’snewintheworldofEHS,oursoftwareandotherrelatedtopics. Connectwiththeauthor FeaturedPosts ExploremoreworkplacesafetyresourcesfromtheEHSInsightBlog. 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