You may have noticed that one of TOP-SET’s straplines is ‘Simply Consistent’. This is not to say that the TOP-SET investigation system is simple (often a term connoting negativity). Nor is it to say that it is so complicated that only a few will understand and be able to do it. It is used because, as Leonardo DaVinci said, “simplicity is the ultimate sophistication”. We have taken something that can often be seen as complex, i.e. investigating an incident and coming up with its causes, and made it beautifully simple.
Complexity is okay though, and different from being complicated. An incident is complex by its very nature of having occurred within a system. Yes, there is lots of information to untangle and assimilate whilst investigating but if you do it the right way, following the steps, and stand back from being mired in the data, what you will end up with is a simple and true explanation of the incident and its causes. “The more you step back and embrace complexity, the better the chance you have of finding simple answers, plus they are often different from the answer you started with” (Eric Berlow, 2010).
It is true that circumstances surrounding an incident under investigation may be complex, but by standing back and remaining objective; by sticking firmly to the process, this actually reduces the amount of potential complications that can arise, such as confirmation bias and internal politics, which ultimately simplifies what you are trying to do. This is not to say that TOP-SET is reductionist in its approach; quite the opposite. The process is there to guide not restrict. Also, because you can follow the same process each time incidents are investigated, you and others will get consistent results.
If you think about it, all we ever want to achieve is to understand something, be able to explain it easily, and learn from it to prevent similar incidents and be proactive in our risk mitigation. Imagine being able to show your superior or teammates a simple diagram and, without even needing to speak and ramble on to try and aid their understanding of what happened; giving examples, excuses, explanations, they get everything they need to know from the root cause analysis diagram. Of course, there is more to it than that, as the report will contain a fuller explanation, and discussion is necessary to determine how to act on the findings, but a picture should literally explain a thousand words. You have navigated the complexity to provide the simple answers. The hard work has been done. A complicated explanation isn’t necessary.
“That’s been one of my mantras – focus and simplicity. Simple can be harder than complex: You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.” – Steve Jobs
This is the essence of TOP-SET and what makes it truly effective. It may look like a ‘simple’ process at first glance, and people may wonder what makes it so special, but it can set you free with its simple consistency and enable you to get on with the job of investigating incidents knowing you’re getting to the root of the problem.
“Truth is ever to be found in simplicity, and not in the multiplicity and confusion of things.” – Isaac Newton
This Ted Talk is not about incident investigation, but illustrates the point: