Evidence and chronology
Bring together the available accounts, records and relevant procedures. Establish the sequence and identify inconsistencies or gaps that need follow-up.
WHAT WE DO / ROOT CAUSE ANALYSIS
Investigate the causes behind an incident.
Creation Train provides root cause analysis. Hannah McKeand’s prior experience includes commissioned investigations in professional guiding. The purpose is to establish what happened, examine why it happened and identify changes that address the contributing conditions.
Discuss root cause analysis
From the event to the underlying conditions
An investigation needs to distinguish evidence from inference. A timeline can establish the sequence; the analysis then examines decisions, procedures, communication, equipment and organizational conditions. Where the evidence is incomplete, the uncertainty needs to remain visible.
SCOPE OF WORK
What the work involves.
Causal analysis
Examine immediate causes and the conditions that allowed them to develop. Test explanations against the evidence rather than assuming the first apparent cause is the whole answer.
Corrective actions
Link recommended changes to the identified causes. Specify responsibilities and how the organization could check whether the actions have been effective.
DELIVERABLES
Documents and outputs.
The scope depends on the brief and the evidence available.
- Incident chronology and evidence summary
- Causal findings with uncertainties identified
- Corrective-action recommendations
WORK WITH CREATION TRAIN
Discuss the work.
Send the brief, the problem or the deadline.