I NCIDENT M APPING SM

Prepare for
Incident Mapping Manage Involvement
A1 A2 C1 C2 G2

Describe the Incident

Primary Event

Map Incident Causes

Known Cause

Identify Circumstances
+ or -
Circumstance

Identify Breached Barriers

Breached
Barrier
Identify Issue Owner(s)
Owner

Perform Root Cause Analysis

Known Cause After
Problem Analysis
Unknown
Develop and Select Solutions Problem
Possible
e Chosen
Barrier Barrier
Possible Chosen
Protect and Action Action
Recommend Actions

710-35-P540916 Copyright 2017 Kepner-Tregoe, Inc. All Rights Reserved. 01 June 2017
 I NCIDENT M APPING
A1 A2
Primary Event
+ Circumstance
Known Cause
- Circumstance
Known Cause After
Problem Analysis
Possible
Barrier
Possible
Action Unknown Problem
Prepare for Incident Mapping
Who should be involved or informed?
Describe the Incident
What is the primary event (Object
and Deviation), location (Where),
time (When), and size (Extent)?
Map Incident Causes
What are the direct, tangible, factual
causes (Object and Deviation) of this
event (Stairstepping/5 Whys)? Do
we have evidence?
Identify Circumstances
How did circumstances (Object and
State) accelerate (+) or limit (-) the
effects and by how much?
Identify Breached Barriers
What barriers (Object and Deviation)
were meant to break the cause-
effect chain, but did not?
SM
C1 C2 G2
Chosen Action
Breached
Barrier
Chosen Action
Owner
Chosen Barrier
Owner
Chosen Action
Identify Issue Owner(s)
Who has the accountability and
authority for which issues
in the cause-effect chain?
Perform Root Cause Analysis
What problems are still to be
a nalyzed? What causes have yet
to be found?
Develop and Select Solutions
What actions (preventive, contain-
ment, corrective, contingent) will fix
the primary event and make it less
likely in the future? Which actions
will be most effective and efficient?
Protect and Recommend
Actions
What could block successful
implementation? How will actions
be protected?
Copyright 2017 Kepner-Tregoe, Inc. All Rights Reserved.
710-35-P540916 01 June 2017