Event Investigation Guidelines

• Step Four:  Analyze Data

This step is where the rubber begins to meet the road. All of the data that you have accumulated and sorted is now analyzed using various tools and techniques to arrive at conclusions regarding the root and contributing causes. The more experience you gain at using the tools we have provided, the more efficient you will become at determining causes. In our experience, we've seen that while "science" certainly plays a role, there is an equal (if not greater) art involved in cause determination.

This step can be quite intimidating to the inexperienced investigator. We have provided you with a large number of tools, each including step-by-step guidelines to help you through the process. While we have provided some suggestions for use, it is up to you to pick and choose those tools which you feel are most appropriate and/or desirable.

Please be reminded that, should you need assistance in your investigation, we have experts standing by to help. We will provide assistance that spans the spectrum from conduct of a peer review of your finished report, to providing a member or two to augment your in-house team, to providing an entire team and event investigation project management. If you need assistance, call us at 877-832-9492 , click here to access our LIVE HELP, or email us at EventHelp@PracticingPerfectionInstitute.com. We're here to help!

Following is a listing and brief description of the tools we have provided for your use. The tools identified are available for your use in .pdf format, which you can print and use as often as you like. Again, if you are interested in customizable / interactive tools, click here for more info.

• Timeline

In our opinion, the Timeline is a good place for you to begin most investigations. It provides a chronological sequence of events in a logical and sensible format.

By constructing and using a Timeline, you are provided with a clear reminder of conditions and factors to consider during analysis and cause determination. It can also assist in formulating interview questions.

As part of the investigation report, the Timeline provides an understanding of the sequence of events that might otherwise be difficult to extract from the investigation report.

• Event and Causal Factor Charting

One of the key lessons learned over the course of event investigation history is that significant events are rarely the result of a single act or component failure. Typically, a "daisy-chain" of errors, failures, and weaknesses are found to have "lined up" to allow the event to happen.

Event and Causal Factor Charting is a tool that will help you understand the sequence of conditions/occurrences and associated causes involved with the event under investigation. This tool is very valuable for evaluating complex events.

• Change Analysis

When an event involves an activity or process that has been previously completed successfully, Change Analysis can provide valuable insight. It can help answer the question, "What was different this time (when the event occurred) from previous performances of the activity / process where no undesirable consequences occurred?"

Change Analysis identifies specific causal factors, and can lead to the identification of additional causal factors.

• Barrier Analysis

In most any activity, "barriers" are installed to keep us on the other side of the table from doing something unsafe or making a mistake. Barriers are both administrative and physical in nature.

Administrative barriers are used to ensure consistent human performance. Examples include procedure steps, training, and the use of Error Elimination Tools.

Physical barriers are used to protect people and equipment, and can include such things as a railing around a mezzanine or catwalk, and interlocks (such as the interlock in your car that requires your automatic transmission to be in Park before the ignition key can be turned to Start).

A Barrier Analysis identifies the administrative and physical controls involved with the event under investigation, and assesses each for effectiveness. By conducting a barrier analysis, you will be able to determine which barriers failed, and which barriers were either weak or nonexistent.

Barrier Analysis is typically used in conjunction with Event and Causal Factor Charting. By superimposing the Barrier Analysis upon the Event and Causal Factor Chart, you can identify where the various barriers applied within the sequence of events.

• Task Analysis

Task Analysis can be used for events where human error appears to have been involved. It guides you through a review of work documents, log sheets, procedures, technical manuals and other associated documents in order to determine task specifics and how they are to be performed.

Basically, the Task Analysis allows you to compare how tasks should have been performed, compared to how they were performed during the event.

There are two basic types of Task Analysis:

• A Pencil and Paper Task Analysis is used to identify what actions are expected to be performed.
• A Walkthrough Task Analysis is used to observe how the task is normally performed (without adverse consequence).

• Fault Tree Analysis

Fault Tree Analysis helps to establish all possible causes for an event. The basic premise is that once all possible causes are listed, a knowledgeable individual (or team of individuals) can consider each possible cause, eliminate non-causes through deduction or evaluation, and (eventually) arrive at the root and contributing causes.

Using Fault Tree Analysis, you will be able to unleash the free-thinking creativity of your right brain, and mesh it with your logical left brain.

• Behavioral Analysis and the How-to-Why Matrix

When human error is involved, this tool helps you identify the mechanisms that influenced the behaviors of the individual(s) involved. By considering the internal factors affecting the individual's ability to order/direct, sense, interpret, or act, you can arrive at an explanation of "how" the occurrence happened.

Once the "how" is determined, the tool can then be used to cross-reference various causal factors that led to the inappropriate act. By so doing, you can draw conclusions about "why" the individual acted in the manner involved with the event.

• Evaluation for Organizational & Programmatic Issues

From the precepts of Practicing Perfection^TM, we know that 84 to 94 percent of all human errors can be directly attributed to process, programmatic, or organizational issues. This tool provides you with a method to identify what organizational and/or programmatic issues contributed to the event under investigation.

This tool also helps to provide you with a "sanity check" relative to the scope and breadth of your investigation.