Basis for System
The Investigation Catalyst supports a systematic inquiry process based on several key thoughts.
- A properly designed inquiry system can be self-directing, requiring minimal training if subjective conclusions are minimized, and adequate criteria are provided for those remaining.
- Investigations focusing on understanding and improving desired (or undesired) system operations, viewed as processes, are most valuable.*
- Processes consist of people, objects and energies, interacting to produce intended or unintended process outcomes. Those actions also create or change conditions.
- The use of a matrix, with time and actor coordinates, guides the rigorous discovery, documentation, organization, coupling, testing, and communication of the actions required to produce the outcomes, in a "flow chart" format.
- "If you can't flow chart it, you don't understand it."
- Proper matrix entries and their organization enable analysts to methodically find any potential changes in behaviors that could be introduced to improve process performance, and predict their effects on future process interactions and outcomes.
For inquiries into mishaps, other key ideas are:
- Gaps in action flows can point investigators to remaining data acquisition needs.
- Actions leave various kinds of tracks, from which the actions can be identified.
- Documenting actions on matrixes as data are acquired expedites investigations, enhancing efficiency.
* Note the positive focus on process improvement, rather than a negative focus on failures, errors, causes or preventing recurrence.
|