Analysis of actual Incidents reveals the following elements:
•What happened (based on factual evidence).
•Which barriers (controls) did not function properly?
•Which causes were leading to the failing barrier?
•Which preconditions (work environment conditions) allowed the causes to happen?
•Which underlying causes (Root Causes) were leading to the working environment?
•Which organizational weaknesses (Basic Risk Factors) were involved?
Based on the analysis action points must be defined to prevent the actual incident from happening again and to prevent similar events from happening.
Incident Investigation will be carried out by an independent practitioner using the Tripod beta technology.