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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