Incident investigation and analysis is an essential part in identification of risks and managing the business process. The quality of the investigation and analysis determines on what level remedial actions can take place. The better the investigation and analysis, the more one finds the systemic causes of incidents. By identifying and remedying these systemic causes, entire classes of incidents can be prevented.

Based on the Tripod theory, Tripod Beta has been developed as an instrument to analyse incidents. Tripod Beta is seen as a state-of-the-art method to analyse incidents. The method itself however is not explicitly designed for fact-finding, although the Tripod Framework does give a clear direction and supports finding facts.

This paper describes a new tool in the Tripod family: TRACK. TRACK facilitates the process of fact-finding and enables the investigator to get away from the "what happened" to the "what made it happen". Results show that using TRACK increases the consistency and objectivity of the investigation, and forces the investigator to dig deeper than with any other tool available.

Keywords:
questionnaire, investigator, precondition, human error, hazard, latent failure, incident investigation, risk and uncertainty assessment, university, active failure
Subjects:
HSSE & Social Responsibility Management, Risk Management and Decision-Making, Contingency planning and emergency response, Risk, uncertainty, and risk assessment
Copyright 2004, Society of Petroleum Engineers
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