Incident investigation has many layers, and under each of these layers are reasons and recommendations that are investigated after an incident but there are always some Internal and intangible layers. The outer layers are directly related to the technical and appearance reasons, while the inner layers are related to risk prevention and root causes. Often, when an incident occurs, only the outer layers are taken into account so that all the information that has led to the high cost of the incident cannot be used. The aim should be to analyze the incidents and learn from them so that we can prevent incidents better than past. This, obviously, does not mean that superficial reasons are less important than root causes and profound ones but it means that all causes must be considered to prevent an incident. When just superficial reasons are considered, only recurrence of the last incident will be prevented. While, by considering the underlying and root causes many similar events might be prevented.
Due to the type and level of incidents, the experts of the company use various techniques such as MORT, Tripod Beta, FTA to understand the scenarios and the way of occurrence and use RCAT, CLC, PII and other techniques to extract root causes and identify areas for improvement in the organization. Also, classic brainstorming methods such as 5 Whys, Fish Bone and Domino’s are used for non-classified events.