Diagrams can provide a useful framework for documenting evidence, identifying causal factors, and identifying gaps in knowledge. They also help prevent inaccurate conclusions by exposing gaps in the logical sequence of events. Where gaps are identified, further analysis can uncover necessary detail.
The incidents we investigate—accidents and near misses—almost never result from one cause. Most of them involve multiple, interrelated causal factors. This complexity should also be reflected in the investigation methodology used. Selecting the right one for your situation can be challenging.
Frequently, an investigation team’s bias can result in narrowly-focused cause analysis. This shortcoming can result in avenues of investigation being left unexplored, which can happen when investigation teams are influenced by their preconceived notions, or jump to conclusions.