Framework
The Investigation Catalyst uses a novel conceptual framework to support a systematic inquiry or investigation process. The main concepts are:
- Treat desired and undesired system operations and occurrences as processes.
- Do investigations to improve future process performance. *
- During investigations, develop and document a description of the process, and develop an understanding of how and why things happen during the process.
- People, objects and energies must interact to produce intended and unintended process outcomes or results.
- Actions are required to create or change conditions.
- Achieve process improvements by changing what people, objects or energies will do.
- Actions during a process can be identified from the various kinds of tracks they leave; find the tracks.
- The timing of actions is essential to understanding what happens during a process.
- A matrix, with time and actor coordinates, disciplines the discovery, documentation, organization, coupling, testing, and communication of the actions required to produce process outcomes.
- "If you can't flow chart it, you don't understand it."
- Gaps in coupled action flows pinpoint missing data needed to complete the process description.
- Necessary and sufficient logic tests of coupled actions determine the completeness of the description and explanation.
- Coupled actions on matrixes enable analysts to methodically find any potential changes in behaviors that could be introduced to improve process performance.
For inquiries into mishaps, additional framework elements are:
- Documenting actions on matrixes as data are acquired expedites investigations, enhancing efficiency.
- Matrixes constrain introduction of unsupported speculations and conclusions during investigations.
- Matrixes enable anyone with data to contribute to the description and explanation of what happened, while the logic testing filters data that are not relevant.
* Note the positive focus on process improvement, rather than a negative focus on failures, errors, causes or preventing recurrence.
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