The Flying Squad applies primarily Tripod BETA™ methodology, but we are also familiar with other barrier and root cause oriented investigation and analysis techniques, a selection of it listed below.
Barrier oriented investigation & analysis techniques
In barrier oriented incident investigation and analysis methods, a barrier is a willfully implemented physical or organizational means in order to either secure the process outcome at hand as planned/ desired, or to structurally mitigate the consequences from deviations from the same. Simple example: cars are generally fitted with ABS in order to prevent collisions (proactively), where applied seatbelts that cannot prevent occurrence of any car collision still are capable of mitigating consequences of the same.
The notion of a barrier will allow application of a visual, symbol-based diagrammatic representation of an incident, AND it allows analytical outcomes from incident investigation to feed into a similar graphical and diagrammatic risk management presentation like the widely used Bow-Tie risk analysis notion.
The barrier-based analytical tool Tripod BETA™ has a number of members, each with distinct characteristics. Besides Tripod BETA™ as barrier oriented incident investigation and analysis method, we also offer:
BFA Barrier Failure Analysis
Barrier Failure Analysis is the least structured Tripod BETA™. It is a pragmatic, general-purpose incident analysis method. It has no affiliation with any particular regulatory organization. Characteristic is the absence of formal rules, definitions or a convention; this may be interpreted both as a strength (flexibility) as well as a weakness (lack of consistency). BFA is a way to structure an incident and to categorize the elements of the diagram according to incident analysis taxonomy. The structure offers events, barriers and causation paths discriminating unspecified Primary, Secondary and Tertiary Causes. Events are used to describe a causal sequence of unwanted events. This means each event causes the next event. It is also possible to have parallel events that in combination cause the following event.
Root cause oriented investigation & analysis techniques
Root Cause Analysis (RCA) aims to find subsequent causes of an incident in a dependency order. Causes may be sought in a logical process, starting with the moment of loss of control. This will help to identify substandard conditions in cause-consequence relationships. The conditions are graphically represented in a diagram that resembles a fault tree. The RCA provides opportunities to identify controls, barriers or defenses to prevent the incident from happening again.
We do not provide Generic Root Cause Analysis methods e.g. 5-Why, Ishikawa Fishbone, Timeline, Event-Fault Tree or Pareto, due to the missing reliability of this methods especially for complex incidents, but the following:
Implements the RCA method as part of a systematic process to find, amongst others, root causes of incidents. This process encompasses seven steps: plan your investigation, determine what happened (sequence of events), define causal factors, analyze each causal factorâ€™s root causes, analyze each root causeâ€™s generic causes, develop fixes, present/report for approval.
The TapRooT-toolset supports several phases in the investigation process. The two most important are the SnapCharT Â®, which supports identifying direct causes by, for example, a process analysis and the Root Cause Tree Â®, to analyse underlying causes. This tree defines four main categories: Human performance Difficulty, Equipment Difficulty, Natural causes, Sabotage and Other factors.
Reference: David K. Ramsay: The Practical Handbook of Investigation, ISBN 1-897667-10-8/ISBN 978-1-897667-10-1
Implements the RCA method as part of a complete incident investigation system being developed since 1988 by Kelvin. The RCA is an element of the TOP-SET investigation methodology that considers an incident as system of interacting components: Technology, Organisation, People, Environment and Similar events set against a Time base. These components are used in the planning phase of the investigation process to open up the perspective, and help to explore the scope and to structure the investigation project. The components‘ 33 indicators suggest areas to enquire and subsequently to allocate actions to the investigation team. After the initial statement, the planning phase is followed by an investigation and analysing phase using the RCA.
Reference: Mark Paradies and Linda Unger: TapRooTÂ® The System for RCA, Problem Investigation and Proactive Improvement, ISBN 1-893130-02-9