ABSTRACT
The goal of incident investigation is not only to understand the “what” and “how” of an incident, but also why it happened. The analysis of an incident begins with the gathering of data. As the data are gathered, they are organised and analysed using causal factor charting, fault tree analysis, or the “5-Whys” technique (or other appropriate tools). The goal is first to identify the causal factors for the incident. Causal factors are those contributors (human errors, problems, and external factors) that, if eliminated.
