incidentanalyses

Incidentanalyses are systematic examinations of events that disrupt normal operations to understand what happened, why it happened, and how to prevent recurrence. They are conducted across sectors such as industrial safety, healthcare, aviation, information technology, and public safety, and aim to improve reliability, safety, and resilience.

The analysis typically starts with data collection from multiple sources, including incident reports, logs, witness or operator interviews, physical evidence, and digital traces. A reconstruction of the timeline is often built to identify sequence of events, decisions, conditions, and failures that contributed to the incident.

Analytical techniques commonly used include root cause analysis, the 5 Whys technique, Ishikawa (fishbone) diagrams, fault tree analysis, and barrier analysis or bow-tie methods. Analysts may perform qualitative assessments, quantitative risk evaluations, and causal chain mapping to link local failures to systemic weaknesses.

Outcomes of incident analyses include a structured report that documents findings, root causes, contributing factors, and recommended corrective and preventive actions. Reports should specify action owners, timelines, and criteria for effectiveness, and are often used to guide policy changes, training, engineering controls, or process redesign. Learning is shared to prevent repetition.

In practice, incident analyses inform safety management systems, incident response programs, and quality assurance efforts. They rely on non-punitive reporting, data integrity, and cross-disciplinary collaboration to identify systemic risks and promote continuous improvement. Limitations include incomplete data, bias in interpretation, and the challenge of attributing causality in complex sociotechnical systems.