TABLE OF CONTENTS If an organization has never had a method for formally investigating incidents and yet still learned something from past mistakes, why is a structured approach needed? Why should time be invested in performing an incident investigation?
While something may be learned from every incident just by performing a cursory investigation, much more can be learned by using a structured approach, such as the SOURCE methodology. Since the SOURCE methodology is efficient as well as structured, the user can learn more from the investigation without much additional effort.
An unstructured approach to incident investigation can allow an organization to prevent the same incident from recurring, but unstructured approaches often don t do much to prevent similar incidents.
Example 1: A pump fails. Using an unstructured analysis, the company discovered that the pump failed because of a bad bearing. So, the bearing was replaced and the pump was started again.
With this approach did the organization learn something from this failure? Not much. How could more be learned from this incident? One means would be to get answers to the following questions:
Why did the bearing fail?
Was the correct bearing installed?
Was it installed correctly?
Was the bearing made of the correct material? If it was made of the wrong material, how did the organization allow that to occur? Why did a bearing of the wrong material...
