Upcoming Cause Mapping Public Workshops

September 6-8, 2016

Investigation Basics

By Mark Galley

Many organizations consider a filled-out report form to be a completed incident investigation.  Too often these report forms only identify general issues like human error, equipment failure and training less than adequate.  These general causes obscure the specific causes for the particular issue being investigated.  It is the specific causes that reveal the specific actions necessary to prevent an incident from occurring.  Visually mapping the specific cause and effect relationship for a given issue provides an extremely effective method for a group to understand how an incident occurred and how it can be prevented.  This visual approach matches the very nature of the causal system that comprises every incident.  To develop a prevention culture within an organization, teams should concentrate on identifying the “system of causes,” rather than the mysterious, yet widely sought after “root cause analysis.”  The search for a single “root cause” contradicts the systems approach to analyzing an incident effectively.  This paper will cover the three fundamental steps for investigating an incident:

1) how to outline the magnitude of the incident,
2) how to map the specific cause and effect relationships and
3) how to evaluate solutions to prevent recurrence. 

Three different media for creating, documenting and communicating visual maps will also be explained.  A demonstration using readily available desktop tools, like Microsoft? Excel?, to electronically capture and distribute an analysis throughout an organization will be provided in the presentation.