A combined approach to incident cause analysis: Squeeze every drop of info from undesirable events. (February 2023)

• Record Type: Journal Article
• Authors: Ferjencik, Milos; Bily, Tomas; Frybortova, Lenka
• Is Part Of: Safety science. Volume 158(2023)
• Publication Date: 2023-02
• Subjects: Sequential incident model -- Systemic incident model -- Flaw -- Incident cause analysis -- Combined approach -- IPICA 2.0; AI Adverse Influence -- B/R Barrier/ Regulation -- CAST Causal Analysis based on System Theory -- CE Causal Event -- E&CFC Events and Causal Factors Chart -- HFACS The Human Factors Analysis and Classification System -- HPES Human Performance Enhancement System -- IPICA Integrated Procedure for Incident Cause Analysis -- MoC Management of Change -- MORT Management Oversight and Risk Tree -- RBPS Risk Based Process Safety -- RCA Root Cause Analysis -- SAFRAN SAfety FRactal ANalysis -- SMS Safety Management System -- SRCT Summary Root Cause Table -- STAMP Systems Theoretic Accident Modelling and Processes -- SUCT Summary Underlying Cause Table -- VT Vulnerable Target; Industrial accidents -- Periodicals; Accident Prevention -- Periodicals; Safety -- Periodicals; Travail -- Accidents -- Périodiques; 363.11
• DOI: 10.1016/j.ssci.2022.105997
• Languages: English
• ISSNs: 0925-7535

Abstract

Graphical abstract: Highlights: Sequential and systemic approaches to cause analysis provide equivalent results. Their combination and complementarity can increase efficiency of analysis. IPICA 2.0 procedure was developed to benefit from the combined approach. IPICA 2.0 combines RCA / IPICA and CAST methods with bow tie diagrams. The application of IPICA 2.0 is demonstrated on example from process industry. Abstract: In socio-technical systems, undesirable events are a potential source of information about what needs to be improved. However, it is necessary to understand their causes. The presented IPICA 2.0 procedure for the analysis of underlying incident causes combines two published methods of cause analysis: Sequential method IPICA_Lite and systemic method CAST. The combined procedure of IPICA 2.0 is based on the knowledge that sequential and systemic approaches are not in conflict but complement each other. The article clarifies their equivalence and complementarity which increases the quality and effectiveness of cause analysis. The procedure improves the internal checking of the analysis completeness by using a third descriptive alternative – the bow tie diagram, in addition to the sequential and systemic incident models. The flowchart of IPICA 2.0 allows the practitioners to choose from a combination of approaches the one that will allow them to get to the hidden underlying incident causes most effectively. All steps of the IPICA 2.0 procedure are illustrated by an example.