Top Five Incident Analysis Tips
1) Collect ALL the data:
It is important that you do not rush into the analysis before really checking that you have done all you can to gather the information you need. Some individuals are more likely than others to go for closure, the solution, before all the investigating has been exhausted. Guard against this. An analysis can only be as good as the information input.
2) Clarify what you are investigating:
Your starting point must be clear before you can take the logical steps to drive down, asking the question ‘WHY?’ each step of the way, towards the underlying and root causes. In the beginning lies the ending.
3) Ask ’WHY?’ at each stage:
It may seem like a ‘Primary School’ process at this stage but this real paring down, this keeping simple, is what yields a progession of responses which lead you to the underlying causes and so the foci for your eventual recommendations. Taking ’baby steps’ is the way to clarification in many processes. Root Cause Analysis is no different.
At this stage too, discussion and openness lead to a much more effective analysis. Stay with your Post-its; don’t try to write down your analysis or put it into your computer until you have thoroughly worked it through on the Root Cause chart with stickies. The flexibility of this system allows intelligent, open interaction to really bear fruit in the validity of your results.
5) Hang Loose Within the Framework:
If your question ‘WHY’ seems to yield more than one response, then be comfortable with that. It is OK to have ‘something’ and ‘something’ appearing on the root cause analysis (e.g. poor training and lack of supervision).
There is no perfect template: do remember as you carry out your analysis that there is no format you are likely to produce which is the definitive version. If you have worked according to the TOP-SET® data collection method using the indicators and the Storyboard chart, and if you have worked your analysis asking the question ‘why’ at each stage driving down until there are no more possible responses to be made, then your version is accurate. Remember the newspaper reports. Different reporters for different papers will present the facts of an incident or event slightly differently though the actual occurrence is the same. A Root Cause Analysis for any given incident completed by several different investigating teams (as an experiment or on a TOP-SET® Course) may be different in appearance but will be saying the same thing and will provide the same information for reporting and recommendations.