BlackBox Analysis Diagram

The Root Cause Analysis method that is used in the TOP-SET method (See 3.1 Root Cause Analysis (TOP-SET®)) is changed and simplified for the use in the BlackBox tool. BlackBox is a software tool that guides you through all phases of incident analysis. The tool is used for reporting smaller, low risks incidents or near misses and to analyze the underlying causes. The program consists of a fixed workflow which leads you through all these steps to make a complete incident report. It is designed in a way that makes sure all fields are filled in to get standardized reports that contain the same sections. This gives more guidance and makes it easier to make quick but accurate analyses.

TOP-SET incident investigation BlackBox is based on the TOP-SET® incident investigation and analysis methodology. This method threats the incident as a system that the organization has lost control over. Something needs to be different or changed from the situation before to get the system out of balance. The dynamics of a system can be expressed in different components. TOP-SET has identified six elements to investigate what has caused the incident: Technology, Organization, People, Similar Events, and Environment that are displayed against Time (the acronym of the word TOP-SET). The cause of the incident can be found in at least one of the five elements but most likely in an interaction of more than one element. The Time element can be a check on the causality of the facts found in the other five elements. In BlackBox the Time element is used in the ‘Sequence of Events’ step in which Events and their time before incident can be identified. The elements Technology, People, Organization and Environment are used in the Incident Analysis. At least one of these elements should be worked out in order to find the underlying causes. The element ‘People’ is in red in the Figure below because this element always plays a role in every incident.

 

 

In the BlackBox Analysis investigation diagram you analyze at least one of the four elements of the TOP-SET method that you feel played a role during the incident: Technology, Environment, Organization and People. For each of the chosen elements an analysis is made. This analysis per element consists of minimal 3 maximal 5 items containing Immediate Causes, Missing Barriers and Underlying Causes. The analysis starts with a single Immediate Cause that triggered the incident directly. The reason for the Immediate Cause to occur is the next item; the Missing Barrier. After the Missing Barrier has been identified the reason for this barrier to fail is explained by the Underlying Causes. You need to analyze at least one with a maximum of three Underlying Causes. All the causes in the diagram should be linked with a generic cause from a predefined list. The four elements and the Immediate Causes and Underlying Causes all have their own generic cause’s lists, making eight different lists. Therefor the analysis will contain a specific description of the user and a linked generic cause. The generic causes of different incidents can be compared with each other because they are all picked from the same list in BlackBox. The different generic causes can be counted to make a trend analysis.

 

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