What are the best ways to identify contributing factors in an incident investigation?

1 Systems thinking

Systems thinking is a way of understanding how complex systems work and how they interact with each other. Systems thinking helps you to look beyond the immediate events and actions that led to an incident, and consider the wider context, such as the organizational culture, the policies and procedures, the equipment and technology, and the external environment. By applying systems thinking, you can identify the underlying system failures that created the conditions for an incident to happen, and address them holistically.

2 Human factors

Human factors are the physical, psychological, and social aspects that influence human performance and behavior. Human factors can affect how people perceive, interpret, and respond to information, risks, and tasks. Human factors can also contribute to human errors, which are often seen as the main cause of incidents. However, human errors are usually the result of system failures, not the cause. Therefore, instead of blaming individuals, you should use human factors to understand why people acted the way they did, and what factors influenced their decisions and actions.

3 Causal analysis

Causal analysis is a method of identifying and analyzing the causes and effects of an incident. Causal analysis helps you to trace the causal chain from the initial event to the final outcome, and identify the direct, indirect, and root causes of an incident. There are different tools and techniques for causal analysis, such as the 5 Whys, the fishbone diagram, the fault tree analysis, and the bow-tie analysis. By using causal analysis, you can determine the contributing factors that led to an incident, and prioritize the most critical ones for corrective actions.

4 Data collection

Data collection is the process of gathering and organizing relevant information and evidence about an incident. Data collection is essential for conducting a reliable and accurate incident investigation. Data collection can include interviewing witnesses, reviewing documents and records, inspecting the incident site and equipment, taking photographs and measurements, and testing samples and materials. By collecting data, you can verify the facts and details of an incident, and identify any gaps or inconsistencies that need further investigation.

5 Data analysis

Data analysis is the process of interpreting and evaluating the data collected from an incident investigation. Data analysis helps you to find patterns, trends, and relationships among the data, and draw conclusions and recommendations based on the evidence. Data analysis can involve using qualitative and quantitative methods, such as coding, categorizing, sorting, comparing, calculating, and visualizing the data. By analyzing data, you can validate or refute your hypotheses and assumptions, and support your findings and arguments with data.

6 Reporting and learning

Reporting and learning is the process of communicating and sharing the results and lessons learned from an incident investigation. Reporting and learning is important for improving safety performance and culture, and preventing similar incidents in the future. Reporting and learning can include writing and presenting a formal report, briefing the management and staff, disseminating the information and feedback, and implementing and monitoring the corrective actions. By reporting and learning, you can demonstrate accountability and transparency, and foster a culture of learning and improvement.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?