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5 Whys | 5W | Developed by Sakichi Toyoda; formalised within the Toyota Production System in the 1930s–1950s | Simple equipment failures and process deviations where a single causal chain is plausible | Define the problem clearly; ask 'Why did this happen?' and record the answer; repeat for each answer until the root cause is reached (typically 5 iterations); verify the causal chain; identify corrective action | Root cause statement and single corrective action | Fast to apply; requires no specialist training; promotes iterative thinking; low resource cost | Tends to produce a single causal chain and may miss contributing factors; analyst bias can steer conclusions; less suited to complex or multi-causal events; depth depends heavily on facilitator skill |
Fishbone Diagram | Ishikawa / Fishbone | Developed by Kaoru Ishikawa at Kawasaki Heavy Industries; introduced in the 1960s; popularised in quality management literature | Brainstorming contributing causes across multiple categories for manufacturing defects, quality failures, and process incidents | State the problem at the fish head; identify major cause categories (commonly: Man, Machine, Method, Material, Measurement, Environment); brainstorm causes within each category; identify root causes from the diagram | Cause-and-effect diagram (Ishikawa diagram) showing categorised contributing factors | Visual and intuitive; encourages team participation; covers multiple cause categories simultaneously; widely recognised format | Does not show causal relationships between factors; can become cluttered on complex incidents; may encourage confirmation bias toward pre-set categories; does not prioritise causes |
Fault Tree Analysis | FTA | Developed at Bell Telephone Laboratories (H.A. Watson) in 1961 for the US Air Force Minuteman ICBM programme; widely adopted in nuclear and aerospace industries | Complex technical systems where catastrophic or high-consequence top events must be analysed for all contributing failure combinations | Define the undesired top event; identify immediate causes using logic gates (AND / OR); decompose each cause to lower-level events; identify basic events; calculate probability if quantitative analysis is required | Fault tree diagram with Boolean logic gates; qualitative minimal cut sets; optional quantitative probability estimates | Rigorous and systematic; handles complex multi-cause logic; supports both qualitative and quantitative analysis; well-suited to safety-critical design review | Time-intensive to build for large systems; requires engineering expertise; tree must be validated to avoid missing branches; retrospective application after incidents can be resource-heavy |
Failure Mode and Effects Analysis | FMEA | Developed by the US military (MIL-P-1629) in 1949; widely adopted in aerospace, automotive (AIAG), and medical device sectors | Proactive risk assessment of designed systems or processes to identify and prioritise potential failure modes before an incident occurs | List system components or process steps; identify potential failure modes for each; determine effects of each failure; assign severity, occurrence, and detectability ratings; calculate Risk Priority Number (RPN = S×O×D); prioritise and address high-RPN items | FMEA worksheet with ranked failure modes and recommended actions | Proactive and structured; produces auditable risk register; widely accepted in regulated industries; supports design improvement before deployment | Labour-intensive for complex systems; RPN scoring can be subjective; does not model interactions between failures well; typically single-failure focused rather than combination-failure focused |
Bowtie Analysis | Bowtie | Conceptual roots in Fault Tree and Event Tree Analysis; Shell's major-hazard risk management practice formalised the bowtie diagram in the 1970s–1980s; widely adopted in process safety | Major hazard and process safety scenarios where both prevention (threats to top event) and mitigation (consequences after top event) barriers must be visualised | Identify the hazard and central top event (the 'knot'); map threat pathways on the left side; map consequence pathways on the right side; identify barriers (preventive and mitigative) on each pathway; assess barrier effectiveness and degradation factors | Bowtie diagram showing threats, barriers, top event, and consequences on a single visual | Communicates risk controls to non-specialists clearly; covers both prevention and response; supports barrier management programmes; widely used in major hazard industries | Can oversimplify complex causal chains; barrier effectiveness assessment is qualitative unless supplemented with quantitative data; large bowtie diagrams can become difficult to manage; does not replace detailed fault tree or event tree analysis |
Incident Cause Analysis Method | ICAM | Developed by the Australian mining and resources industry (BHP Billiton group and collaborators) in the 1990s based on James Reason's Swiss Cheese Model and organisational accident theory | Serious workplace incidents and high-potential near-misses in mining, oil and gas, and heavy industry where organisational and systemic factors must be captured alongside immediate causes | Gather facts at the scene; identify absent or failed defences; identify individual and team actions; identify task and environmental conditions; identify organisational factors; formulate recommendations at each level | Structured investigation report with findings mapped to absent defences, individual/team actions, task/environmental conditions, and organisational factors | Explicitly captures systemic and organisational contributors; based on recognised human factors theory; encourages recommendations beyond the immediate cause; structured output aids consistency | Requires trained investigators; more time-intensive than simple RCA methods; can generate large numbers of findings that are difficult to prioritise; less suitable for minor incidents |
Tripod Beta | Tripod | Developed by Shell and Leiden University (Professors Wagenaar and Hudson) in the early 1990s; based on cognitive and organisational accident research | Oil and gas, chemical, and major hazard incidents where latent organisational conditions and basic risk factors must be identified alongside immediate causes | Map the incident timeline; identify unsafe acts and immediate causes; trace to preconditions (Tripod factors); identify underlying Basic Risk Factors (BRFs) in eleven categories (e.g. hardware, procedures, training, communication, incompatible goals); develop recommendations | Incident report with causal tree mapped to eleven Basic Risk Factors | Grounded in cognitive and organisational psychology; eleven-factor taxonomy supports systematic scanning; produces comparable data across incidents; widely used in Shell and oil and gas sector | Proprietary framework (licensed tool required for full implementation); eleven-factor taxonomy requires training to apply consistently; cultural fit is strongest in oil and gas environments; less widely adopted outside that sector |
TapRoot | TapRoot | Developed by System Improvements Inc. (Mark Paradies and Linda Unger) in the early 1990s; widely used in nuclear, oil and gas, and utilities sectors in the United States | Significant incidents and near-misses where a systematic, guided process is needed to identify root causes and develop actionable corrective actions | Collect evidence and sequence events on a SnapCharT event timeline; identify causal factors; use the TapRoot tree (Root Cause Tree) with yes/no questions to reach root causes across categories; develop corrective actions linked to each root cause | SnapCharT event timeline; Root Cause Tree with identified root causes; corrective action plan | Structured questioning reduces analyst subjectivity; Root Cause Tree covers a broad range of human performance and equipment causes; widely accepted in regulated US industries; produces traceable, auditable output | Proprietary and requires licenced training and software; can be perceived as complex for simple incidents; root cause categories are framework-specific and may not align with other taxonomies; resource-intensive for routine events |
Systematic Cause Analysis Technique | SCAT | Developed by the International Loss Control Institute (ILCI) and associated with Frank Bird's Loss Causation Model (1969 updated edition); ILCI later became part of DNV | Workplace accidents and near-misses across general industry where a structured guide-word approach is needed to trace immediate causes to basic causes and management system deficiencies | Describe the incident; identify contact type and immediate causes (substandard acts and conditions); identify basic causes (personal and job factors); identify management system deficiencies using a structured checklist; develop corrective actions | Completed SCAT chart mapping incident to management system root causes | Guide-word structure reduces analyst variance; explicitly connects incident causes to management system gaps; relatively quick to apply after training; aligned to ILCI Loss Causation Model used in many corporate HSE systems | Less granular on human factors than ICAM or Tripod; guide-word lists may not cover highly novel failure modes; output quality depends on analyst familiarity with the model; not as widely cited in academic literature as some other methods |
HSE Incident Investigation Methods Reference 2026
Structured reference of 9 well-documented root-cause analysis and incident investigation methods used in health, safety, and environment (HSE) practice.
Details
- Publisher: SmartQHSE Ltd (https://www.smartqhse.com)
- License: CC BY 4.0
- Format: CSV (UTF-8)
- DOI: 10.5281/zenodo.20446335
- Landing page: https://www.smartqhse.com/datasets/hse-incident-investigation-methods-2026
Citation
SmartQHSE Ltd (2026). HSE Incident Investigation Methods Reference 2026 [dataset]. Zenodo. https://doi.org/10.5281/zenodo.20446335
Disclaimer
Published for reference, training, and research. Consult authoritative sources before operational or compliance decisions. SmartQHSE Ltd accepts no liability for errors or omissions.
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