The need to establish the sequence of events during an investigation of an incident is well accepted. It is the process of creating order from chaos; the ordering of facts as they are understood by the participants, observers and managers, simultaneously and progressively filtered and distilled by available expertise. There is often a lack of information and more data needs to be collected. The process is mired in uncertainty about why and how “it” happened. The intention of creating a fundamental understanding in order to prevent a recurrence is the ultimate goal.
Once the facts of an incident have been established, the sequence typically shows what happened from the very beginning of the event, or the chain of events which lead to the serious negative consequences. One thing leads to another as defences break down or are circumvented. James Reason’s Swiss cheese analogy is often quoted. Read More →