A combined approach to incident cause analysis: Squeeze every drop of info from undesirable events

Abstract

In socio-technical systems, undesirable events are a potential source of information about what needs to be improved. However, it is necessary to understand their causes. The presented IPICA 2.0 procedure for the analysis of underlying incident causes combines two published methods of cause analysis: Sequential method IPICA_Lite and systemic method CAST. The combined procedure of IPICA 2.0 is based on the knowledge that sequential and systemic approaches are not in conflict but complement each other. The article clarifies their equivalence and complementarity which increases the quality and effectiveness of cause analysis. The procedure improves the internal checking of the analysis completeness by using a third descriptive alternative – the bow tie diagram, in addition to the sequential and systemic incident models. The flowchart of IPICA 2.0 allows the practitioners to choose from a combination of approaches the one that will allow them to get to the hidden underlying incident causes most effectively. All steps of the IPICA 2.0 procedure are illustrated by an example.