Answer ‘what happened’ and ‘how to prevent’ in one go
Take your investigation one step further with IncidentXP
IncidentXP feature overview
IncidentXP is our incident analysis software product which allows you to use the most popular and globally used incident analysis methods:
BSCAT links the barrier-based bowtie concept to DNV GL’s concept for incident investigation: The Systematic Cause Analysis Technique (SCAT). SCAT provides a framework with predefined categories of direct and basic causes that have proven to be important contributions for incidents in multiple industries. By applying this SCAT technique on a barrier, one can assess the performance of barriers during an incident and come up with specific improvement actions that address the basic causes of failure. The BSCAT concept supports complex incident investigations that are characterized by a variety of events that went wrong.
Linking incident analysis and risk assessment
The BSCAT method can utilize pre-existing bowties or can be used on its own. It was the first method to complete the Deming circle and link risk assessments with incident analysis. BSCAT is built on top of the BowTieXP platform.
The Tripod Beta method is a way of conducting an incident analysis specified for high risk and complex incidents since it is a very extensive and detailed method. Training is highly recommended when using the Tripod Beta method.
Building a tripod tree
A tripod tree is built in three steps. The first step is to ask the question: ‘what happened?’. All the events that happened in the incident are listed as a chain of events. The next step is to identify the barriers that failed to stop this chain of events. The question that is asked in this step is: ‘How did it happen?’. When all the events and the failed barriers in between are identified, the reason for the failure of these barriers is analyzed. The last question for this step is: ‘Why did it happen?’. For each of the failed barriers, a causation path is identified.
A more detailed explanation of the elements that compose the Tripod Beta diagram are explained in our knowledge base article.
Tripod Beta in IncidentXP
IncidentXP allows the user to easily create a full Tripod Beta diagram, with various useful features that will make the analyst’s job a lot easier.
Barrier failure modes
Within IncidentXP it is possible to indicate within the diagram why a barrier failed. An example of such barrier failure mode is the ‘inadequate barrier’: a rare type of a failed barrier that is used when a barrier functioned as intended by its design, but was unable to stop the sequence of events. It indicates an issue with the design specifications.
Full control over diagram layout
As any tripod analyst will tell you, creating a Tripod Beta incident analysis diagram is an iterative process. Sometimes new facts found in the investigation will shed new light on the incident and will require the analyst to rethink the diagram. This means that the diagram needs to be adjusted. Within IncidentXP you can easily add new components to your diagram and it can easily be rearranged.
Within IncidentXP it is possible to make fully graphical cut-out reports. This report breaks up a tripod diagram in its individual trios and discusses the failure mode of each represented barrier. These reports can be customized with company logos, title pages, tables of content and custom chapter numbering like in a regular Word document.
Barrier Failure Analysis (BFA)
BFA is a pragmatic, general-purpose incident analysis method. It has no affiliation with any particular regulatory organization, so doesn’t contain any predefined lists in comparison to BSCAT. 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. 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.
Analyze which and why barriers failed
Barriers are used to highlight certain parts of our environment as being designed to stop a chain of events. They are not necessarily independent, or sufficient. Since the unwanted events still happened, causation paths are added to explain why the barriers didn’t function properly. The causation path goes three levels deep. The levels are simply called primary, secondary and tertiary level. These labels can be changed according to your organizational standards, but the idea is that a barrier can be analyzed in three causal steps. It does not specify whether the analysis should end on an organizational level or not, although this is what would happen most frequently.
Create causation categories to analyze trends
Each level in the causation path can also be categorized. But by default, there are no categories defined. As there is an infinite number of possible categorizations and a large number of different types of organizations, it is not possible to create one standard of categories that would apply to all. Moreover, it allows creating custom categories. Any organization should go through an initial period of testing and iterating categories. At some point, a steady state should emerge that will capture most incidents, but there will always be exceptions. Once exceptions happen more frequently, they stop being exceptions and should be integrated into the existing categorizations in a new iteration of the taxonomy.
After trends have been spotted, actions can be taken for long-term risk management approach.
Why Barrier Failure Analysis?
There are several reasons to choose for Barrier Failure Analysis:
- Barrier-based analysis methodology
- Plot incidents onto the proactive bowtie risk assessment diagrams
- Bowtie risk assessment can be used to check if the incident analysis covered everything
- Customizable causation categories
- Generate actions to improve your current risk situation (short-term) and risk analysis (long-term).
Root Cause Analysis (RCA)
RCA is a 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. 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.
Improved RCA categories and cuts
First, we added some more subtle categorizations 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, making it 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 the overview.
Barriers or RCA
The main difference between RCA and our other incident analysis methods is that RCA is not barrier-based. In RCA everything is an event, while some of these events would be considered barriers in BSCAT, Tripod Beta or BFA. It is no problem if you just want to use RCA, but there is one thing to keep in mind. Whereas the barrier-based incident analysis methods like BSCAT and Tripod Beta can be mapped back onto the bowtie due to their similar (barrier) structure, RCA is not able to provide this link. The bowtie structure depends heavily on identifying barriers, which is not the case in RCA.
TOP-SET Root Cause Analysis
The Kelvin TOP-SET® Root Cause Analysis method is an incident investigation methodology that follows all known best practices in this field. The method revolves around six elements: technology, organization, people, similar events, environment and time. The planning of the investigation, but also the facts that are gathered during the investigation are categorized by these items.
The TOP-SET® methodology starts with an initial incident statement to set the scope of the incident. After that, the method basically follows three main steps: plan, investigate and analyze.
Planning is a very important step in the TOP-SET® method. The investigator is guided in the planning to make sure not a single possible factor of the incident is overlooked. The TOP-SET investigation planner provides you with a list of all possible factors making sure that the investigator has a broad perspective on the incident.
In this part of the investigation, all actors contributing to the incident are investigated. Witnesses are interviewed, the incident scene is visited, pictures are taken and simulations are performed. During the Kelvin TOP-SET® course, all these techniques are taught (more information can be found on www.kelvintopset.com). When all facts are gathered they are gathered on a storyboard and categorized in the six main elements. The storyboard items can be of different colors showing the credibility of the item or the investigator that added it. Since time is an important element, the storyboard can also be transformed into a timeline.
3. Analyze – root cause diagram
When all facts are gathered the investigator can look at the causes of the incident. In the TOP-SET® method, this is done through a root cause diagram. The diagram starts with identifying the immediate causes, then the underlying causes (failed barriers) all the way to the root causes. These root causes represent the latent failures of the organization. When these failures are resolved the incident will be prevented in the future together with a scope of similar incidents.
Some incidents can have an overwhelming amount of information. The timeline offers a diagram that structures an incident investigation and creates an overview in chronological order, making it easier to manage the investigation.
The timeline in IncidentXP is a grid consisting of time on the x-axis, and actors on the y-axis. Actors are the major components in an incident. A person, a piece of equipment, a process, a management system or anything else that logically groups findings can be actors on the y-axis.
Once the facts are ordered in time and by actor, they can be assigned a confidence level and a category. The confidence level ranks facts by how confident we are that they are true. The category indicates where they are likely to appear in the incident analysis which follows the fact-finding phase.
- Quick drag & drop reordering of facts
- Assess confidence levels of facts
- Attach evidence to facts
- Add color to indicate meaning and increase overview
- Export the timeline as a picture
- Report the timeline in Excel or Word.
In IncidentXP a user may select one or more methods to analyze an incident and after this selection the analysis can start. From here, the user may choose to build up the diagram from the treeview as normally done also in BowTieXP. Another option is to use the incident manager functionality which will guide the user through all the steps of the incident analysis. This easy to follow process ensures that a thorough investigation process is done and no steps have been forgotten. At the end of the analysis process, a standardized report can be generated. This report can be based on a company template that adheres to the company standards.
Link with BowTieXP
Besides being a tool to analyze incidents, IncidentXP also allows you to use BowTieXP risk assessments to check if the investigation covered everything that was identified in the bowtie.
After this has been done, the final results link back to the bowtie risk assessment to aggregate and detect trends across incidents. This allows an organization to maximize learning from incidents. It also ensures the bowties are continuously updated and improved. With this, IncidentXP allows organizations to take the next step in learning from incidents.
Link with SIR in BowTieServer
One of the modules in BowTieServer, Scenario-based Incident Registration (SIR), makes it easy to report an incident without going through an entire analysis process. SIR is meant to capture barrier data on incidents with medium complexity. Predefined bowties of common incidents and tailored questions help provide context and understanding while making the report. The result of the SIR is a list of failed barriers and the reasons why they failed. After that, the result can be further analyzed if needed in IncidentXP with the incident analysis method of your choice.
Link with action tracking in BowTieServer
BowTieServer also offers an action tracking module, for managing ‘lessons learned’ as improvement actions. This will allow you to allocate, manage and track all your actions and recommendations. In this way, you can capitalize on the findings coming from your incident analysis.
Read more about the BowTieServer modules here.
Reporting from IncidentXP
After the incident investigation has been conducted through IncidentXP you may want to submit a report with the findings to management or to the relevant regulator. You can report information in a case file in various ways using the built-in reporting engine.
There are many different types of reports with different functionality and visualization of the information. Based on the investigation or what a receiving party wants to see, you are able to choose style and content. It is also possible to integrate an already standardized company template into the IncidentXP reporting engine.
Don’t take our word for it…
“BowTieXP makes it easy to create bowties and to discuss and adjust the outcome with our line managers and operators, due to the way it visualizes the assessments. The feature to highlight failures or combine it with audit and test results also prove to be very helpful here. When we have a serious accident, we use IncidentXP to find out what went wrong and what we overlooked in our BowTies. All in all, it’s a well-integrated solution.”
“In case of an incident, the use of IncidentXP and BowTieXP has allowed us to: graphically visualize the risks and controls existing in a railway operation scenario; globally analyze the effectiveness of technical, organizational and human factor barriers; as well as to facilitate internal communication that promote the safety culture, within the Railway Safety Management System.”
“Barrier failure or weakening is often a causal factor in accidents and incidents. State Supervision of Mines uses bowties to identify the weak barriers by analyzing different incidents. The insights from the bowties are helpful in assisting the gas network operators with their safety programs.”
Combine with our other software solutions
BowTieServer unites different risk disciplines in a single, central repository with bowties and related information. It combines all the powerful tools we offer and unifies them across the organization.
BowTieXP is the most advanced software tool based on the bowtie method. The visual risk assessment the method provides improves risk understanding, communication and management.