Introduction
The theme of any incident investigation is prevention. The principle at the core of any incident or problem is cause and effect. Most people and organizations use a singular approach to causal analyses looking for the one cause that created the problem. In reality every incident is a systems issue comprised of multiple parts or causes. A Cause Map provides a visual picture of the causes of an incident, just as street map provides a visual of the streets. Cause Mapping is a simple three-step process for
1) Clearly outlining the problem,
2) Mapping the cause and effect relationships and
3) Identifying specific actions to control specific causes.
Cause Mapping can be used by individuals to troubleshoot a single problem or by an entire group to investigate a significant event. Though the Cause Mapping process is effective for investigating incidents one of the benefits is how an organization begins to approach problems. As an organization becomes better at reactively understanding a problem, it also becomes better at preventing incidents from ever occurring. Proficiency at reactively analyzing issues develops the thinking necessary to create a prevention culture. In this paper there is no distinction between investigating a safety incident and any other type of problem. The cause and effect principle and effective communication are fundamental to any investigation. The visual approach of Cause Mapping makes capturing and sharing information in an analysis much more thorough and effective.
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