Many companies repeatedly experience the same type of incidents. Investigations indicate what seem to be the right solutions, yet the same type of incident occurs again and again! What are needed are investigation methods that, used in the right combination, will always leads to the right solutions, regardless of industry or setting.

Investigating Incidents 
Incident investigation, whether for safety, quality, or production, can be simple or complex depending upon the severity of the event. In principle, investigators would be trained to [a] discover the facts, [b] collect evidence, [3] ascertain the root cause(s), and [4] make recommendations in a written report. However, many investigators often seize on the first set of ‘symptoms’ as the Root Cause, rather than the Root Cause(s) themselves. This is why the same type(s) of incidents are often repeated.

Root Cause Analysis
Root Cause Analyses helps you get to the 'bottom' of events to prevent recurrence. A Root Cause is the most basic cause (s) identified as contributing to an incident, and that is within peoples control to fix. A number of tried and tested methods are available to help identify these most’ basic’ causes. These include ‘Influence & Causal Factor’ Charting, the ‘5 Why’s’, ‘Fishbone’ or ‘Ishikawa’ Cause & Effect Diagrams and Applied Behavioral Analysis (ABA). Each of these methods is in widespread use throughout industry with their pedigrees going back to the early 1970’s. BSMS trains investigators how to use each of these methods in various combinations to ensure all the angles have been covered.

Influencing & Causal Factors
‘Influencing & Causal Factor’ charting is a method used to diagrammatically represent a series of events that lead up to the incident, and any ‘influencers and causal factors' associated with each event as shown below.

Causal Bucket Matrix
With each of the methods, our detailed matrix of ‘Causal Buckets’ can be used as a guide for investigators to assign each aspect of an incident into its Basic, Immediate And Root Causes. Always considered a work in progress, the matrix covers some 11 ‘Basic Cause’ Buckets, containing 39 ’Immediate Cause’ Buckets, which collectively contain some 350 universally applicable Root Causes.

Training
BSMS provide high quality training in Root Cause Analysis.

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