The Latent Cause Analysis

Go Page The 5 Items

The 5 Items

 

The Five Items should ALWAYS be your investigative starting point. When you get the call to investigate, your immediate response should be to request these 5 Items. If you are investigating a Maxi event, the person who called you should supply these items for your review. If you are investigating a Midi Event, your team or crew should develop the 5 Items.  If it's a Mini event, it is your responsibility to develop the 5 Items.

  • Statement: One or two paragraphs, describing "what happened," including WHO, WHAT, WHERE, and WHEN. Intended to be BRIEF, to the point, and written by ONE person to summarize the ESSENTIALS so that evidence freezing can begin promptly.

  • Schematic: A HAND-DRAWN schematic of the system, equipment, or component involved in the incident -- NOT an engineering drawing pulled from the files, but HAND-DRAWN -- showing the essence of the state of things at the time of the incident.

  • Relationship: Another HAND-DRAWN schematic, this time showing the RELATIONSHIP of the system, equipment, or component involved in the incident to the rest of the facility.

  • Sequence: A brief summary sequence of events, written by ONE person (approximately 5 bullet-points).

  • List of Oddities: Aside from the failure itself, was anything odd about this incident?

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