Incident Investigation: Analyzing the Facts and Causes shows you how to conduct a root cause analysis to help identify the key factors that contribute to an incident. You'll also see how to follow a line of questioning that can lead you to the underlying causes of an incident to help you determine the systems that need to be strengthened. Once you've interviewed witnesses and collected evidence, the data may seem overwhelming. What should you do with that data? How do you identify key factors?
Step Four: Determine All Contributing Factors
The next step in the investigative process is to use all of the information collected to funnel out the facts and determine the key factors. Key factors are the circumstances that may have contributed to an incident.
They can seem unrelated to the incident, but are crucial in building a case for recommendations and solutions. Key factors will form the basis for recommendations for corrective action and follow-up.
Areas to Explore
When determining key factors, the areas you'll want to explore are — physical factors, human factors, and operating systems.
Getting to the Key Factors
Once you've identified the possible factors and initial questions, it's time to use root cause analysis to identify and confirm the key factors. You do this by asking "Why".
Step Five: Determine Systems To Be Strengthened
Look at the systems related to the key factors. If you discovered an underlying problem with one of the systems that determines how work gets done, it must be addressed to prevent a potential recurrence of the incident.
Systems to consider include operating procedures or safe work practices, management of change, training, contractor safety, communication, emergency planning and response, assurance procedures, and equipment systems.