INVESTIGATION CATALYST
Quality Assurance Tutorial
© 2004 by Starline Software Ltd.

REPORT QUALITY ASSURANCE TUTORIAL

5. Create Accident Report Matrix

This part of the Tutorial takes the Accident Report EVENT BLOCK (EB) data you have prepared and inputs it into the INVESTIGATION CATALYST application to build a Matrix displaying your data for further analysis. This and the next exercise will enable you to see how the Matrix can help you with investigation or quality assessment tasks.

This exercise takes the data identified in the Accident Report and inputs the data to display, organize, analyze and use it to help the investigation.

  • For guidance using the software, use the HELP menu in INVESTIGATION CATALYST, or contact. techsupport@starlinesw.com, using techsupport as subject.
Step 1. Assemble data.

Use either your own marked up copy of the report or the list of event blocks or the samples provided, as the data source for this part of the tutorial
Step 2. Prepare Matrix.

Open INVESTIGATION CATALYST and set up the Title page with the name of your Project and edit any defaults with TOOLS > MATRIX PROPERTIES or Command+y.

Set the Matrix preferences with CATALYST > PREFERENCES > Matrix display tab, clicking on ACTION, OBJECT, LOCATION AND SOURCE only; make sure other boxes are unchecked. Select Timeline Display DATE AND TIME check box. Select Other Tab and set the AUTOSAVE and backup preferences. Close Preferences and then save the empty matrix using your file name.


Step 3. Enter data

Start entering data from EBs noted in your documents, arranging the sequence manually from time to time. Use Command+b to open the Build New Event Block panel for data entry.

Use Command+i to open the Inspector, make changes, and press return to record the changes.

Refer to FAQ or INVESTIGATION CATALYST HELP menu when you have any questions about how the application handles Event Blocks..

Step 4. Compare results

After completing your Matrix, compare it with the Matrix provided. With your Matrix open, open the Matrix "TR_Matrix.mes" and view it to see how they compare.

Next, with your Matrix in the active window, use FILE>IMPORT to import the file "TR_Matrix.mes" into your matrix. You will be warned of duplicate EBs during the import process: Select SKIP for each duplicate, which will add only different EBs. After the import is complete, view your file to see what was added: these are the differences between your matrix and the school solution, if any. If you can not understand the differences, save the merged file as a compressed MES file, and send it to Starline techsupport with your questions.

Step 5. Dealing with gaps

When you get your EBs entered and sequenced, examine the EBs and try to link those that are causally related, using tentative or dashed arrows when the relationship may be inferred in the report, or not made clearly.

Next, start adding Question or Alert Comments when you see a ? or a gap or dashed link in the scenario that you can not visualize, or any other questions that the display suggests. Use the Comment icons on the TOOL BAR to add new comments.

A report should provide data for a complete flow chart of the incident. Anything less indicates a quality shortcoming.

Refer to FAQ or see the INVESTIGATION CATALYST HELP menu when you have any questions about how the application handles links and comments.
Step 6. Diamonds option.

If you care to pursue problems indicted by the report, try to find EBs where you can identify a concrete problem in the process described. Add Diamonds to those EBs. Using the INVESTIGATION CATALYST Diamond feature, fill in the blanks in the Diamonds panel. For more information about these tasks, see the Recommendation Tutorial.

This exercise will illustrate the ambiguities in the report. It also shows how to use partial Matrixes for possible interim control actions to restart an operation.

Step 7. Further options.

In actual cases, you would save and print the partially completed Matrix and use it to guide subsequent investigation tasks. Share it with other investigators, witnesses or anyone else who might be able to help you add more EBs and build a complete valid mental movie.

Top

FREQUENTLY ASKED QUESTIONS (FAQ)

For Step 3 - Entering data:

Q 3-1. If data is unclear, ambiguous or otherwise imperfect, can I fix it before entering it as an EB? No, if your purpose is to assess the quality of the document. Maybe, if your purpose is to try to understand what happened, and you can persuade a skeptical user your interpretation or inference does not change the essence of the document.

Q 3-2. How often should I arrange the EBs in their chronological order? After about 3-5 entries if you are positioning your new EBs manually. If you are entering dates and times, use the Snap EBs to Time every 10 or so EBs, or more often if you feel more comfortable seeing them develop.
After adjusting positions manually, use Snap Time to EBs icon in the tool bar to set the relative positions quickly. If you want to position two EBs at the same time, use the Inspector to enter the same begin date and time in both.

Q 3-3.How can I move more than one EB at a time manually? While holding down shift, click on as many as you want to move, and then drag the select EBs as a group. The selected EBs that will be moved will have a light blue border until they are de-selected or move.

Q 3-4 What should I do about missing dates and times? Use approximated or estimated times, entering increments appropriate to the scenario that is unfolding, as it is recorded. Do not forget to use the Confirmed check for any times that were reported. With data and time entries, EBs can be arranged with one click on the Snap EBs to Time icon.

Q 3-5 Why bother with color codes? To let everyone know what investigation tasks are still needed during the investigation, and after it's over to let everyone know if any of the attributes of an EB are unusual. With this report, you should be prepared to indicate inferred or unfinished EBs on your Matrix.



Top For Step 5 -Comments:

Q 5-1 If I resolve the questions or comments, can I remove them? This is a policy question. You may want to keep them in a work file that you save after the project is complete so you have an audit trail for the investigation, and then save the file with only those comments that are still needed after the investigation is complete.

Q 5-2 How should I link EBs that indirectly influenced what happened? With a regular link at this stage. The Necessary and Sufficient test will reveal any extraneous or missing EBs when you examine the links with the Inspector.

Q 5-3 What should I do about linking ambiguities like partial names or incomplete action ? Get better information or make a comment about your problem and add it. Note how the matrix illustrates the ambiguities in the report.

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