TOP-SET® Root Cause Analysis
The company Kelvin TOP-SET® is located in Scotland and has over 20 years of experience in incident investigation. The knowledge that came from this experience is incorporated in a methodology, named TOP-SET®. TOP-SET® 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: Planning, 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 in the incident is overlooked. The TOP-SET investigation planner gives you a list of all these possible factors making sure that the investigator has a broad perspective on the incident.
In the investigation part the investigator looks at all the factors he or she wants to find out. Witnesses are interviewed, the incident scene is visited, pictures are taken and simulations are performed. During the TOP-SET® course all these techniques are taught (for more information go to www.kelvintopset.com ). When all the facts are gathered they are put on the storyboard, which is 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 also an important element, the storyboard can also be transformed into a timeline.
When all the facts are gathered the investigator can look at the causes of the incident. In the TOP-SET® method this is done with a Root Cause diagram. This 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.