Lecture 11 - Creating an Event Time Sequence

Question 1

Step 1: Collect evidence

Answer 1

• Any recordings: from CCTV, security, witnesses, bystanders, …
• Phyiscal evidence: like in crime scene investigations; e.g. marks, prints, tracks, residue, samples, locations,…
• Documentation: e.g. training records, procedures, manuals, checklists, notes, permits, records, logs, reports,…
• People Involved: interviews with those who were involved in, observed, or have information about the incident

Question 2

Step 2: Combining the evidence into a chart representing sequence of events over time

Answer 2

• # Event time sequence should include:Short incident description (e.g. employee sustaining cut to hand, or pump catching fire, or tank overflowing)
  Detailed sequence of events leading up to and following incident
  Details/conditions surrounding each event, explaining why this event happened
  For each event include the agent involved (who/what did this?)
  ===
• Whilst putting the sequence together, using sticky notes for events and conditions can be handy, it allows for easy rearrangement

Question 3

Step 3: Improving the chart

Answer 3

• As the investigation progresses, you will be able to add more details to the chart
• Initial versions will point to areas that need further investigation
• Try to sort further details/conditions per event they relate to
• Logically arrange conditions to show what led to what (like a causal tree, see separate lecture on tools and techniques)

Question 4

Symbols

Answer 4

REFER TO SLIDES

Question 5

Step 4: Determining causal factors and root causes

Answer 5

• Identify those events/conditions that form the direct causes of the incident (failures or problems without which the incident would not have occurred) – these are the causal factors
• For each of those causal factors, use the root cause categories checklist (see separate resource) to dig for deeper underlying causes, to identify applicable root causes
• Use checklist to identify root causes for any other significant issues identified in the chart
• Checklist can also be used to check if any applicable problems have been overlooked in the chart
• Note that the checklist is not exhaustive, one should not restrict oneself to only looking for those causes included in the checklist