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Root Cause Analysis for Incident Investigation
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IncidentXP is our incident analysis software product which uses the same software framework as BowTieXP. This makes it possible to link incident analysis information to risk assessment information. However, IncidentXP can also be used as full-fledged stand-alone incident analysis tool.
The software is designed to learn from all incidents that have occurred in your company. The type of incidents may range from process deviations, to near misses, to small incidents, to major accidents. And the incidents can relate to both Process Safety and Personal Safety.
Learning from incidents is a challenge for most organizations. One of the biggest reasons for this is that the analysis performed on the incident does not provide an adequate basis for high quality recommendations which will change the organization for the better while still being realistic. IncidentXP will assist you in making recommendation focused on a specific barrier or on the organizational level (basic risk factor level).
Only using incident analysis is not enough. Bowtie risk assessment can be used to check if the investigation covered everything that was supposed to be done before we finalize an incident analysis. Additional, the incident analysis results should link back to the risk assessment to aggregate and detect trends across incidents. By providing both risk assessment (BowTieXP) and risk monitoring (IncidentXP) we close the circle of Deming (plan-do-check-act) within 1 software framework.
Root Cause Analysis is an add-on module to the BowTieXP software or can be used as a standalone module using IncidentXP.
The Root Cause Analysis method is a simple and straightforward incident analysis technique. It starts with an incident and drills down into the chain of events that led to that incident until the root causes are identified. This method is widely used throughout the world, and the idea of drilling down to the root cause is also present in all of our other incident analysis methods.
It provides a lot of freedom in explaining the causality of the incident: what caused what? The Root Cause method aims to get to the bottom of your incident. RCA practice tries to solve problems by attempting to identify and correct the root causes of events, as opposed to simply addressing their symptoms. By focusing on correction of root causes, problem recurrence can be prevented.
RCA diagrams are similar to BSCAT diagrams without barriers, rotated 90 degrees / in top-down direction instead of in left-right direction. In technical terms they are a directed acyclic graph rooted at the top.
However, a traditional root cause analysis has the potential to turn into a jumble of elements. We felt this could be improved, so we did two things. First, we added some more subtle categorisations so you can see at a glance where the real problem areas are. You don't need to use them, but if you do, we think you will create better analyses, and it will be easier for your audience to see what you're trying to communicate. Second, you can cut up a large diagram into smaller pieces, and link them together. Separating the main diagram from sub-diagrams avoids a situation where the diagram becomes so large you lose overview. We hope these changes to RCA will help you create better analyses.
RCA will include all the features you expect like reports, case file overviews, import/export options, easy manipulation of the diagram, scrap book support, find and replace, spell checking, undo/redo, auto-save, and many others
The main difference between RCA and our other incident analysis methods, is that RCA is not barrier based. Everything in RCA is an event, including those things that would be considered barriers in BSCAT, Tripod or BFA. This doesn't matter if you just want to use RCA, but there is one important caveat. Whereas the barrier based incident analysis methods like BSCAT and Tripod can be mapped back onto the bowtie because their structure is similar, RCA cannot be linked back to a bowtie, because the bowtie structure depends heavily on identifying barriers, which RCA does not do. The other possibilities are being examined for the future development of this Add-on module, like classifying events. But we will base that development on real world feedback.