(141a) Sherlock Holmes, Why Trees, Bow Ties, and Investigating Process Incidents

When investigating crimes, Sherlock Holmes was an expert at observing important facts and deducing from them significant insights into what had happened.  When investigating process incidents, PSM professionals similarly need to observe and develop important facts about what happened and deduce from them what might have caused the incident and how it can be prevented in the future.  Are there things we can learn about incident investigation from Sherlock? This paper will review some key methods for investigating process incidents, applying appropriate insights from Sherlock. In particular, use of the why tree method for determining the root causes of incidents, and use of the bow tie method to better understand the contributions from failed or missing layers of protection, will be discussed.