In this methodology, we conduct a reliability analysis of what went right by asking a series of 'what if' questions to reveal deeper learnings:
o What if the consequences were different? o What if the process was different? o What if the environment was different? o What if the plant was different? o What if the operator was different?
If we ask the "what if?" question four additional times, we get four alternate realities in addition to the actual sequence which occurred. That provides a much richer tapestry of system deficiencies and, therefore, recommendations for system improvements. To explain the process, each sequence in the linear incident trajectory and the four alternate trajectories can be linked back to the event and causal factor analysis diagram with each dot on the diagram representing an actual failed or absent defence; or, in the alternative trajectory, a point of vulnerability. The investigation report is then not just about linear causes but about vulnerability to future events which may adopt a different trajectory. The investigation is therefore not simply a root cause analysis, but a vulnerability analysis where the aim is to build resilience in the system to safeguard against an unpredicted and unexpected future event.
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