While forensic investigation and establishment of technical cause – effect relationships are usually well understood and handled adequately, incident Investigations are struggling to integrate human and organizational factors into causal analysis. The tendency is to focus on nearby factors, factors that where close in time and space to the actual incident. In many cases the investigation stops when a human error has been found. However, it is evident that other factors play a major role in system failures.
The purpose of the course is to equip the incident investigators with the capability to investigate complex incidents by using simple yet effective tools. Special emphasis is on integrating the human and organizational factors that surrounded the incident and subsequently using these to identify underlying causes as well as issuing adequate recommendations.
The course can be adapted to any company preferences with regard to investigation method (Root Cause Analysis (RCA), Tripod, Fishbone etc.). The standard proposed method included is SIM (Simple Investigation Method) which is characterized by its ease of use while combining causal analysis with barrier based thinking.
The course material includes easy to use templates for investigation analysis, report writing and presentation based on Microsoft Office applications. Hence, avoiding investing in expensive software solutions.
The Incident Investigation Training Program
The core content of the training is tailored to each client but includes the following elements in a three-day training:
- Why incident investigation?
- Requirements on the Incident Management process
- Getting the right mandate
- Individual versus team investigations
- Recording the incident –including assessing the risk
- The generic steps of an investigation
- Collecting data (identification of data sources)
- Structuring and analyzing data (timelines, SIM)
- Findings and conclusions
- Issuing useful recommendations (including quality markers for self-check)
- Handing over to management
- Introduction to human and organizational factors
- Introduction to accident causation theory
- Investigator mindset in order to move from first stories to second stories
- Investigation exercise including data gathering (desktop), interview situation, analysis and discussion about conclusions/recommendations
One additional day can be added to further build skills:
- Report writing
- Report writing exercise
- Handover meeting to management