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Software Manual and Training guide For version 3.2

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1. z 8 Communications Radiological Factors SIMILAR EVENTS 10 Error Inducing Conditions Organisational Memory 11 Other WD 00 J mm LA Fa PE kj i 5 Personal Protection 10 Other Figure 4 1 TOP SET Planning Card Step 1 Planning Planning the investigation and gathering data involves using the TOP SET indicators a set of 600 prompts which are arranged according to six categories Technology Organization People Similar Events Environment and Time This set of prompts or indicators is what leads to the success of any TOP SET investigation The TOP SET Planning card shows a summarized version of the full set of indicators see Figure 4 1 TOP SET Planning Card This card is shown in the software The Investigation Planner The indicators are used as prompts to help the user to think of as many events or issues as they can that may have contributed to the incident The indicators can be revisited as often as necessary 14 Step 2 Storyboard The issues identified are then investigated and the resulting data lay out on a Storyboard chart organized by TOP SETO category and time Step 3 Analysis At the analysis stage of the investigation which comes after the investigation has been planned carried out and all of the contributing events have been investigated and laid out on the Storyboard Following the TOP SET method a Root Cause Analysis Diagram is made In this diagram the causes of the incident are analyz
2. B Layout all Children Ctrl Z Undo Ctrl Y Redo Ctrl Shift P Pan Ctrl Alt N Hide or Show Balloons 13 3 Analysis Diagram windows 13 3 1 Item Properties Figure 13 6 Properties window 49 Properties Event You can also edit the name description location of event A Detaik date and time and other information in the Item Properties Mr Window on the right side Description Location of Event To the right bottom side of your diagram there is a smaller a window where you can edit information directly ey a ee Asset Value Any changes made here will be reflected instantly in your Persisted over peric diagram B Classification Category Colour Re po rtab le 13 3 2 Overview Figure 13 7 Overview window Figure 13 6 Properties window 13 3 3 Attachments Figure 13 8 Attachments window Adding Notes Choose between the Overview Recommendations and Attachment windows using the tabs at the bottom of the windows A a aie Overview The Overview window shows you a bird s eye view of the entire Tripod Method Diagram Root Cause Diagram This is a good way to navigate a complex Diagram and zero in on portions you wish to edit or move To select a portion of the Diagram use your mouse to drag the green box over the area you wish to focus on The Diagram will snap to the selected section IY Attachm E Recomm Use the Fit button on the toolbar to show the whole Diagram Figu
3. 13 2 Tripod Method Diagram To make a Tripod diagram choose this when you get the Analysis choice see Figure 13 4 Tripod Analysis Diagram or choose Tripod Beta in the drop down lost under Analysis Diagram in the Investigation Workflow at the start page igator 3 3 2 rev 6 Tripod Method Diagram New Investigation View GoTo Tools Help Latent Failure Active Failure Fallue i gt Failed Barrier i Figure 13 4 Tripod Analysis Diagram 45 When the Tripod Diagram opens the main Event is already defined from the one line incident statement From this starting point you can enter arrange and connect the pieces of your investigation using the shapes and definitions associated with the Tripod Method Figure 13 4 Tripod Analysis Diagram e Event e Object e Hazard e Barrier e Active Failure e Precondition e Latent Failure To start your Tripod Diagram e Double click in the Event item to create a Hazard and an Object for your first trio Make sure to deselect the option Enable single click editing of shapes in Tools gt Options gt Diagram e You can continue double clicking on every item in the diagram to create the next most logical step of building your Tripod tree The items will automatically be connected e You can create additional items by using the Actions button in the toolbar double clicking on existing items or by double clicking on a blank area of
4. Figure 13 8 Attachments window cecessesessesessssessssessesssssssssessesessssecsssecsssesssesessecssseessseeeseeneseesees 50 PU NN INOS AA eE O e E mA 50 Adding images and other attachMent cecsssssssssssesssssessesessssssssssesssssesssssssseeseesecsccscssssucsussussssessessesseeseeseeseesecuccucsucsusseesesseeseeseeseeneenee 51 14 0 RECOMMENDATIONS 82 EXECUTIVE SUMMARY ccssssssssssscssssssssccccsssssssssssssscsssccssccsssssssssssees 52 1AAARECOMMENDA TON Sec c acc cha gets emcee tt tios 52 To group the Recommendations table e g by person responsible eccecesseessecessessssecsssessssecsssesssseesssesesseessseessseeneseeeees 53 To filter the Recommendations tablei aiii 53 154 E OTT N E A E eee ere treet 54 iS REPORT enaena A ces 56 TLEAN OUT OF TAE REPORT ainia aiii an aaa 57 MO TING THE RECON sario det E OAE 57 HOW TO INSTALL INVESTIGATOR 3 MSI vrcssssdoscsscscsuesescdsesesctesvscovedasseavcdatadssodevasceddsvadecadavas ssduetedenssavsecntdessesests 58 HOW TO INSTALL INVESTIGATOR 3 ZIP a 62 ATTACHMENT A How to install Investigator 3 MSI cc ccccscssessseseeeseeseceeeesecesesseceecseeesecseessecseceseseceseesseeeeseeeeeeaeees 55 ATTACHMENT B How to install Investigator 3 ZIP eee cecccescsseesseeseeeseeesecssecesecesecesecesecssecesecsecseeeceseseeeseeeeeeeseeeeesass 59 2 List of Figures Foure Group activati eeror a E A EEEO TAE darted OO tioned EAO 9 Foure A a 10 EIQUES 5 O ACUV AM
5. Select printer 4 Print To print the overview 5 Page setup To get an overview of the page before printing 6 Scale Choose the scale to view the report with 21 TO Jl 12 13 14 15 16 I7 18 Hand tool Magnifier Zoom Out Zoom Level Zoom In Navigation Multiple pages Background colour Watermark Export Email Word Pan option to be able to move the overview of your diagram around To zoom in on your overview Zoom out of the overview Drop down list with different zoom levels Zoom in on the overview Navigate through the report by going to next and previous pages Show multiple pages at the same time Choose a colour for the background of the pages Opens the watermark window to show watermark colour text etc Export the document in several formats To email the report in a certain format to export the file directly to Word 22 O Incident Details In this first step of the Investigator 3 software you will enter the basic and detailed information about the incident You start with details such as the date and time of the incident and then expand on these to include a short incident statement a list of the incident s consequences and a detailed description of the incident Here you also add information about the people who were involved in the incident It is important to be thorough with this step As with all the information you enter these details will be used to populate your report
6. see Figure 9 1 Report Introduction amp Method of Work which will be displayed near the start of the report Use the Preview amp Export and the Print buttons in the toolbar to export and print the Report Introduction and Method of Work Report Introduction Write your introduction in the box below Include any extra notes or images in the Attachments section eo Method of Work Write your Method of Work in the box below using the text as a guide Include any extra notes or images in the Attachments section The investigation used the Kelvin TOP SET Incident Investigation methodology E O Specify more information using the following items as a guide Forming the investigation team Planning Site visit Interviewing Eo RI Figure 9 1 Report Introduction amp Method of Work 9 1 Report Introduction To enter a Report Introduction e Simply enter text in to the Report Introduction field that is appropriate to your investigation 31 e You can also copy and paste text in from other applications e Add attachment in the Attachments window next to the Report Introduction section for help see 13 3 3 Attachments 9 2 Method of Work The Method of Work should provide a summary for the reader of how you undertake the investigation It should detail the methodology used what the various steps were and what these entail The TOP SET methodology is already put in h
7. 0 Redistributable When prompted during the download choose Open and Run to install the Framework You can also first save to disk and then open it Install the framework through Microsoft Windows Update Browse to http windowsupdate microsoft com and choose to update your computer Select the NET Framework if it is listed You will probably find it under recommended updates Before you can use Investigator 3 you must have the Microsoft NET framework version 2 0 installed Some computers already have this installed some do not If not you will get a warning while installing Investigator 3 3 4 Investigator 3 site activation Investigator 3 can be configured to activate all members of a global or universal domain user group This is known as site activation The site activation process is as follows Choose Send site ID Receive Activate group to to CGE or LS activation Investigator activate reseller code 3 First choose the user group to activate Investigator 3 creates a site id for this group which must be sent to CGE Risk or another reseller so they can create an activation code for you After entering this activation code into Investigator 3 it is activated and will run Note that the site id can also be retrieved in a different manner and the codes can also be entered in a different manner These alternate methods for site activation are described below the sections which show you the process to follow in
8. 1 AAA interface some of which feature graphics and tools that 2 Tor will help you to thoroughly investigate and analyse the incident while others offer a way of adding textual gt Reportintroduction information The information you enter into Investigator Plan the Investigation 3 will automatically be entered into the report which is TS generated as the final step in the process At the end of Identify the Immediate Causes the process besides the final report all of the information you have entered will be stored in the saved file enabling you to keep all of the information in one place making the whole process of investigation much 7 Analysis Diagram Type Root Cause 8 Make Recommendations less cumbersome 9 Generate a Final Report Figure 5 3 Investigation Workflow The software was created to lead you through the process from the receipt of initial information about the incident all the way through to the reporting process The steps should be completed in the correct order However you are encouraged to move back and forth between the sections as much as you like to refer to information you have already entered General shortcut keys Ctrl N New File Ctrl O Open File Ctrl S Save File Ctrl Shift N Hide or Show Navigator F1 Open help file Alt F1 Introduction help file F2 Go to Incident Details F3 Go to Terms of Reference F4 Go to Report Introduction F5 Go to Plan Investigation F6 G
9. 59 4 Download the installer 5 Open the file double click icon 6 Run the software 7 Start the Wizard 7 of download php from www governorsmansion nl Co 1 a 9 a download php from www governorsmansion ni Estimated time left 4 hr 22 min 59 2KB of 15 4MB copied Download to C Users estella Investigator 3 2 4 msi Transter rate 1 41KB Sec Close this dialog box when download completes Open Open Folder Smart5creen Filter checked this download and did not report any threats Report an unsafe download The publisher could not be verified Are you sure you want to run this software Name O Users estella Desktop Investigator 3 2 2 msi Publisher Unknown Publisher Type Windows Installer Package From C Users estella Desktop nvestigator 3 2 2 msi Always ask before opening this file This file does not have a valid digital signature that venties its publisher You should only run software from publishers you trust How can decide what software to nun The installer will guide you through the steps required to install Investigator 3 on your computer WARNING This computer program i protected by copyright law and international treaties Unauthorized duplication or distribution of this program or any portion of it may result in severe civil or criminal penalties and will be prosecuted to the maximum extent possible under the law Cancel 8 Select installat
10. Copy details to clipboard This will copy the Current Host ID shown to the clipboard Paste the Activation details into an e mail and send your request to support governors com We will then send you an activation code and an activation dat license file that can be put next to the executable by hand or in an installation script This license file will auto activate the software for any user who is a member of the user group 12 4 Methods Used in Investigator 3 Investigator 3 has been developed by investigators for investigators It has been developed for the professional investigation of large scale incidents It is the latest in a series of innovative incident investigation software tools developed by TOP SET Governors BV Investigator 3 is a totally new product which builds on the structure of the previous Investigator tool developed by Kelvin TOP SET On top of that the incident analysis method Tripod Beta is also included in the software This way the two best practice methods in incident investigation are brought together The TOP SET incident investigation method uncovers more relevant facts during an investigation by pointing out every factor that could have played a role This solid investigation basis is required for sound Tripod Beta analysis by providing better quality data Investigator 3 has been built to replicate as closely as possible the paper based TOP SET incident investigation methodology Investigations are tradi
11. GOVERNORS RISK MANAGEMENT amp CORPORATE GOVERNANCE 4 gt Investigator 3 The Incident Investigation and Analysis tool Software Manual and Training guide For version 3 2 1 Contents E CONTENTS naaa iaa 2 2 USFOFPPFIGURES sintio iii ias 5 3 INSTALLATION INSTRUCTIONS uscar 6 A OA e a o oo O BOO E II A eae A 6 Touca TIS SO WIR rr dida 7 3 2 SYSTEM RIN I Si oidos 7 gt THEMICROSOFT NET FRAMEWORK ae 8 3 3 1 Watts PCOS ANNE ona 8 3 3 2 Is the NET Framework already installed u ccececscsssssssssessssessssessssessssessssessssessssesssesessesssessseseesesssesessesesseceeseaesseeness 8 3 3 3 If you are not allowed to install software on your PC wa cececesscsesssssssssssesessssesessesesessesescsseseseesesescsesesceseseeseseaeseseees 8 3 3 4 Install the framework from the Investigator 3 downloads site u cececsesessessssessssesessessssesessecesseeessesesseceesesesseesess 8 3 3 5 Install the framework through Microsoft Windows Update cccecsessssecsssessssesessessssessssesessesessesessesssseeesseeneseeness 8 3 4 INVESTIGATOR 3 SITE ACTIVATION oran 8 3 4 1 COOSA GOOD Oa V e E E esate ics 9 a URAAN as 10 0 EV ORIN LTO A A E A A A ORE N 12 4 METHODS USED IN INVESTIGATOR 3 sims 13 4 1 TOP SET INCIDENT INVESTIGATION METHODOLOGY ssssssssseseseseseseseseseeescsesesesesesesesesesesseseseseseseseseseseseeeeeeneneneneseneaeaes 14 SS ccsesssssesesssssescsscsesessessessessecsecsecsccuscucsucsussussussussussusssesessecsess
12. It is important that the Incident Statement describes the exact incident you are investigating as it will provide the starting point for your analysis There are three sections Basic Information Detailed Information and People Involved You can click on the tabs to select on or you can use the Previous and Next buttons Previous 7 1 Basic Information Tab E Basic Information 2 else eR Giclee ieee Eee E EEE 1 Titling Information Report Title New Investigation Report Version Draft 1 0 ld Gp Add JK Remove ACE Company Name category a JE Click the Add button to create a new Person 2 Incident Details Date and Time Location 14 October 2009 14 14 T 3 Type and Severity Tick all that apply Breached Security io Damage to Business Performance Damage to Property or Equipment Damage to Reputation Environmental Damage E Fatality or Serious Injury Near Hit or Miss Other Injury Check if reportable under law Figure 7 1 Basic information Tab 23 On this first tab you need to enter the basic details about the incident see Figure 7 1 Basic information Tab Titling Information e Add a report title e Add the names of the authors of the report press the Add ar button to add new authors e Add job title information e Add employer information Incident Details e Add the date and time of the incident e Add the location of the incident Type and Severity
13. Users estella Desktop Investigator 3 2 3 Inve publisher You should onl nun software from publishers you trust B This file does not have a valid digital signature that venfies its How can decide what software to run 12 Choose how you want to run the software TOP SET GOVERNORS Investigator 3 This product is not currently activated or about to expire Please follow the instructions below and contact your software supplier if necessary Activation Status Activation Type Not Activated Expires 15 August 2009 Run in Trial Mode 30 days remaining What would you like to do Get an Investigator 3 Activation Code Enter Activation or Trial Code
14. You can also let the time change when you reposition the item on the storyboard For this you need to go to Tools gt Options gt Storyboard then select the option Change date and time Now when you reposition the item on the storyboard the time changes too You can change the time periods when you enable the timeline on the Storyboard in the options Go to Tools gt Options gt Storyboard and append and delete items with the and buttons If you make a new item indicate how many seconds before the incident the item takes place This way the software knows exactly where the item will be located A Details Item Properties Figure 11 2 Properties window Name mixture with oxigen Description Location of Event When you click on a sticky note on the Storyboard the Date Time 12 11 2005 6 01 15 AM details associated with that note appear in the tem Time Before Incidenti Properties window A Hoke Persisted ower period Information is grouped by type Details A Classification EsDliciticann B and Miscellaneous C Category Colour C Misc Reportable Figure 11 2 Properties window 39 e You will see that the event name appears next to Name e As you move the sticky note the date and time of the event and the category will change depending on where you position the note e You can color code sticky notes using the drop down menu next to Color in the Classification section Click in t
15. description of the Incident e When it happened e Where it happened e People Involved e Injured People e Other People e Findings of the Investigation e Timeline of events e Immediate Causes of the incident e Underlying Causes of the incident e Root Causes of the incident e Appendixes e Analysis Diagram either Tripod or Root Cause e Persons Interviewed e Injury Reports 15 1 Layout of the report There are several adjustments you can make for the layout of the report e Background color click on the Color Mm button in the toolbar to choose a background color for your report e Watermark click on the Watermark A button in the toolbar to open the Watermark window Here you can choose all the options for the watermark like text color size or if you would like a picture as a watermark You can also change some Watermark settings in Tools gt Options gt Report e Company logo go to Tools gt Options gt Report Here you can right click on the report logo to edit or change it to your company logo 15 2 Exporting the Report There are several ways to export you report e Use the Word m button in the toolbar to export directly to Word see 37 Figure 15 2 Word Report The software will then ask you to name you word report and if you want to open the file In Word the report will be fully editable The report is already put in a template where the contents are automatically updated when you make changes in the chapters Jus
16. e There is a list of possible outcomes that occurred as a result of the incident Check the boxes that apply e Make sure to click on the Check if reportable under law checkbox if this applies to the incident 24 7 2 Detailed Information Tab People Involved 1 What Happened One line Incident Statement 2 What Were the Consequences 3 Detailed Description of Incident Actual Consequences Click here to add a new Consequence Mo consequences have been added Potential Consequences Figure 7 2 Detailed Information Tab On this tab you will enter more specific information about the incident see Figure 7 2 Detailed Information Tab What Happened e Condense the incident down to a specific one line sentence Make sure that you decide at this point what specific incident you are investigating Take care not to describe a more general incident in error What Were the Consequences e Add the consequences of the incident Click on the uppermost field in the consequences area enter your text and press Enter to add each consequence Delete consequences by placing the cursor at the end of the text you want to delete and use Backspace Click outside the field to continue e Add any potential consequences that could easily have occurred if circumstances had been a little different 25 Detailed Description of Incident e Enter a narrative which explains the entire incident in more detail This will b
17. note go to the Actions menu and select Add Item right click using your mouse and select Add Item or simply double click on the graphic To add or edit text double click in the sticky note to zoom in and add or edit text Click in the background of the Storyboard to zoom out again or press enter To do this you have to deselect the option Enable single click editing of shapes in Tools gt Options gt Diagram You will see at the top right of the graphic that the Incident Statement and Consequences of the incident are shown This is to remind you of the specific incident you are investigating so that you do not get too side tracked by the events you are working with Right click on the sticky note items to delete them You can modify the sizes of the sticky notes by selecting the Free sizing of shapes option in Tools gt Options gt Diagram You can also modify the text size by using the big A and small a A buttons in the toolbar You can position the sticky note according to when the event occurred and which category it belongs to Turn on the timeline by clicking on the Show Time Periods button in the toolbar and just click on the sticky note to grab it and move it around the Storyboard EA Show Time Periods You can change the time on the items in two ways First you can change the time in the Properties window gt Date amp Time If you move the item around you see that time in the mouse over of the item
18. the user interface Error Reference source not found Choosing a group to activate Most domain computers will show a lot of groups to choose from It is always possible to lock to the built in Domain Users group This group will be present in every domain A better solution is for the computer administration department to create a special group to hold all the users which are licensed to use Investigator 3 By doing this it is easy to reassign licenses between users After selecting the user group to activate the site id for the selected group is shown The selected site id should be sent to CGE or another reseller so an activation code can be generated Investigator 3 Activation ee P SET GOVERNORS Investigator 3 1 Choose activation type Select an activation type from the drop down below If you require site activation click Show Groups then select the required group Activation type Selected Group ID E A 2 Send us your details To receive an Activation Code please e mail us the above details If the Create E mail button does not work with your email program please instead use Copy to Clipboard and manually paste the details into an email addressed to activate topsetgovernors com i Create E mail A E Copy details to Clipboard Cancel Figure 1 Group activation After receiving the activation code it can be entered into the dialog to activate Investigator 3 See 3 5 User acti
19. to show all of the actions for which a particular individual is responsible Only the action items that are visible in the action list will be exported or printed 37 11 Y Develop the Storyboard After making all the action items the investigation is executed When all the answers to the questions of the action items are answered they can be collected in the Storyboard The Storyboard is a platform where all the facts and information can be gathered On the Storyboard platform you can place yellow sticky notes represent the different events that contributed to the incident and show the timeline involved see Figure 11 1 Storyboard The Storyboard is divided into five categories Technology Environment Organisation People and Similar Events and is organised by Time from left to right with the time the incident occurred at the very right hand side of the graphic Incident Statement Man cut by moving chainsaw Consequences Cut leg with the potential for Severe injury possible loss of leg Figure 11 1 Storyboard 38 Sticky Notes You can add sticky notes to the Storyboard by double clicking in the background A new blank item will appear When clicking in that item you will be able to add text You can also right click in the background of the storyboard to add the investigation findings which you filled in at the Planning editor Those are the results of your investigation using the Action Planning List To create a sticky
20. use connected security enhanced solutions through the use of Web services Before you can run Investigator 3 your computer must have the Microsoft NET framework version 2 0 or higher installed Microsoft advises Windows users to install its NET Framework because of the growing number of framework connected applications on the market Chances are it is already installed as it is also delivered by Microsoft using Windows Update Is the NET Framework already installed You can simply install Investigator 3 and try to run it If the framework is missing you will be notified and can install it then You can also manually check to see if you already have the NET Framework 2 0 or higher installed by clicking Start on your Windows desktop selecting Control Panel and then double clicking the Add or Remove Programs icon When that window appears scroll through the list of applications If you see Microsoft NET Framework 2 0 listed it is already installed and you do not need to install it again If you are not allowed to install software on your PC We have designed a special version of Investigator 3 for users who don t have installation rights as is often the case on corporate networks This version of Investigator 3 with integrated NET Framework can be downloaded from the Investigator 3 downloads site Install the framework from the Investigator 3 downloads site Browse to the Investigator 3 downloads site Find and select the NET Framework 2
21. you desire You can also add or remove items on the list by clicking on the appropriate Add op or Remove buttons 35 Investigation Planner Planning Action List Enter and edit your Actions in the table below You can group sort and filter by any column only displayed Actions will show in the Preview Print ap Add Xx Remove Drag a column header here to group by that column Indicators al Action Planning Issue o Action Required Person Responsi Pri Due Completed Edit People Knowledge 8 Find out if the employees working at the Decisions moment of the incident had knowledge of the tasks process executed and made the right decisions Buncefield Major L Normal 16 09 2 Technology Operations amp find out what operations and processes were Processes executed the day of the incident ce Technology Equipment amp Find out what equipment was involved in Maintenance the incident Buncetield Major I EN Environment Pollution amp Find out if there was pollution or Contamination contamination as a consequence of the Buncefield Major 1 incident People Communications Find out how the workers communicate with each other on the job yy g Buncefield Major I Defeated Controls or Barriers Find out how explosions occured E Buncefield Major I y F Changes and Differences Look for changes or differences in procedures processes etc in the near time Bun
22. Analysis Diagram s The investigation should consider the following 1 Requirements and compliance with company standards pA The effectiveness of safety critical barriers An interim report should be completed by 28 October 2009 with a final report by 13 November 2009 lt Main Author gt 14 October 2009 A E Edit Default Terms i Figure 8 1 Terms of reference To edit the Terms of Reference e Simply edit the text as you wish the existing text is just for guidance e Ifyou wish to start again click the button Reset to Default Terms e Be sure to save your work using the Save button so that you do not lose your edited text 29 If you wish you can edit the default terms so that they appear as you wish them to each time you use the application e Click on the Edit Default Terms button to edit the existing text e Edit the default Terms of Reference in the Default Terms of Reference window so that they appear as you wish them to e Ifyou wish to start again click Reset e Once you are finished click OK e You must restart the application for the edited Terms of Reference to be displayed If you wish to reinstate the default terms e Click on Tools then Reset User Settings e You must restart the application for the default Terms of Reference to be reinstated 30 Zz Report Introduction In this section you can create a Report Introduction and a Method of Work
23. Children Layout All Children Then there is a Delete option to delete the item Figure 13 5 Right mouse click menu Tripod 48 The next options are for the layout of the children items evolving from the selected item of the item Layout Immediate Children Layout All Children Then there is an option to convert the item to another item With this option you can change the item into another item of the Tripod Diagram The last option is to hide child or parent elements of that particular item Then there are a few options that count for only particular items Event Hazard Object The option to Append Event and Append Event and Convert to With this option you can append an extra Event in the trio With the option convert to you append an Event and you can also convert to item to a combined node for example Event Hazard combination Barriers The first Barrier option is to move the Barriers left or right as opposed to other Barriers The next option is to flip the Barrier With this option you can turn the Barrier upside down to optimize the layout of the diagram The Causation path will also be drawn downwards to make the layout more efficient The last option for the Barrier is to insert another Barrier to the right or left from that item You can choose to add a Missing Barrier a Failed Barrier or an Effective Barrier Diagram shortcut keys Ctrl F Fit Diagram Ctrl L Layout Diagram Ctrl A Select all Ctrl
24. O NIDAD Ln e dan ns dos Dane bar Oh do sn lo tind 11 HIUS o L ACUDA ciao iaa 12 Ac LO a A WUE TMNT RANTTY Meerrrt erent eure 14 Foure A2 Ti DO Tee ntesdsshcpeasecdeton eluedeaesdntesdssaatouncchatesdcuatonsccdedesde cateaaied af esl ciassaecantonasquessnaesaateatedss 16 Foures LE Start pag Enea EEEE A EE OEN OTO E eben tetera le canas 17 FUERO AN V Md E E O ree rey ree eee TO E 17 Fous ETOP NIENS ana a E eee er en ere 19 Figure 6 2 Opuons OVVIE WS 19 Figure G Basic TOO DARA OET E OOE 20 Figure 7 LBasicinformation TD a 23 Figure 7 2 Detailed Information TaD zsrsr EAN 25 Figure 3 People IMONE Taiana ds 26 Foure AA da 27 FIGUe S Termsior FETC rencia EA AA O E 29 Figure 9 1 Report Introduction amp Method OF WORK vii A AS Ai 31 Figure 10 1 Investigation Planning CaN ostia tot tdt tons 33 Figure 10 2 E Praning e flia 35 EIqure LOs gt Ranning and acuosos 36 Foure Lil Sto YOO ANG musacuaccda ocioteca loco iconos 38 FIqure 12 Properties WING OW ssssn dador 39 Figure i 2 1 The Immediate Cause Wize Cx ios 41 Foure LLANAS S CNO E A 42 Figure 14 1 Recommendations section 1 e sssesssossssessseessesssseosseosseessessseeosstosstesseesseeosstosstesseesseeosstosstesstesserossroseresseesseroseressresss 53 Figure 14 2 Recommendations section 2 se sssesssssssesssesssessserossresseessessseeosseosstesseesssrosstossresseesseeossresseesseesssrossrossresseesserossresseesss 54 Figure 14 3 Executive Summa yoe ai 55 Fours SSL REDOT ta
25. alysis diagrams in one file Tripod Method Diagram 1 3 1 Root Cause Diagram Remember my preference and do not show this again OK Cancel Figure 13 1 Analysis choice The Root Cause Diagram is divided in three parts the Immediate Causes Underlying Causes and Root Causes see Figure 3 2 Activation Dialog 1 Incident Statement Man cut by moving chainsaw Consequences Cut leg with the potential for Severe injury possible loss of leg Figure 13 2 Root Cause Diagram 42 Building a Root Cause Diagram e Like in the Storyboard you can double click in the background to add new Causes You can also right click to add items from the Storyboard e When double clicking on a previous Cause a new Cause with a linked line will appear Vertical lines will get the Why label and horizontal lines will get an And or labels e When hovering over a cause four red triangles appear in each corner of the item You can use these triangles to draw lines in between causes Just click in the triangle and drag a line to a triangle of another item e Tocreate a new Cause you can also go to the Actions button in the toolbar and select Add Item right click using your mouse and select Add Cause or simply double click on the graphic e There are several options to export your diagram Go to Diagram gt Export here you see you can export your diagram to Visio or export it as a metafile You will then save your diagram a
26. are supplier if necessary Activation Status Activation Type Not Activated Expires 15 August 2009 Run in Trial Mode 30 days remaining What would you like to do Get an Investigator 3 Activation Code O Enter Activation or Trial Code 62 Attachment How to install Investigator 3 zip 1 Click on the download link Investigator 3 Beta Downloads Version 3 2 rev 3 Investigator 3 2 rev 3 installer 1254 m8 77 msi for automatic installation Investigator 3 2 rev 3 executable n49mB 35 in a zip file for manual installation Investigator 3 2 rev 3 release notes 517548 0 in rtf includes the changelog 2 Click on Save Fie Doamnivad Do you want to open or save this file dl Name Investigator 3 2 3 zip Type Compressed zipped Folder 14 9MB From Www governorsmansion nl w While files from the Intemet can be useful some files can potentially Y ham your computer f you do not trust the source do not open or save this file What s the isk 3 Save the file Save As GO HE Desktop v 3 Search P p By New Folder Favorite Links Name Size Type Date modified E Documents Estella Groeneweg More Folders pe Public de adminzipp alex antoinette E A Computer bart H di ben b carolien A Network de davy o D d estella oie gt MEL Docume File Folder as Filename Investigator 3 2 3 v Save as type Compress
27. at would take users from the start of the process of investigation right through to the end Users are educated in planning an investigation visiting the scene and gathering data interviewing witnesses creating a Storyboard of events incorporating as much information as possible analyzing the information to discover the causes creating recommendations and reporting a INDICATORS TOPSET WHERE TO LOOK FIRST 7 P Management Supervision I Equipment amp Maintenance What has changed or is different a A ot Methods amp Procedures 2 Buildings amp Structures What controls have been defeated ae j Safety Controls Systems 1 2 3 in i l 4 passat ead sino What can witnesses tell you E a Laa Copas ar Pracka F 7 8 4 Transport Veniches 5 Operations amp Processes Operating instructions T O 7 Materials amp Chemicals Contractors amp Others Resources amp Finance Planning 9 Procurement Purchasing 10 Quality 11 Other A Power amp Energy TECHNOLOGY ORGANISATION 9 Design amp Layout 10 Other Weather Injury amp Potential Injury Natural Efbects P SAS 2 Activities amp Tasks Pollution amp Contamination Cereral Condibons ENVIRONMENT PEOPLE Housekeeping i Knowledge amp Decisions 4 Amtude Bae ce 5 Skills amp Train ng Location l 6 Health amp Fines Flora Fauna 5 i F l s 7 Emotional State Biological Factors
28. ation code you have been given below If you need to enter your original Host ID please click the Advanced button Enter Activation Code Activation Code Activation Status Invalid Activation Code Investigator 3 Activation e AA ens TOP GOVERNORS Investigator 3 Please enter the activation code you have been given below If you need to enter your original Host ID please click the Advanced button Enter Activation Code Activation Code R4CPPF8F ZM77M2V4 Activation Status Code Accepted ho Advanced p Figure 3 3 Activation Dialogs 2 When you want to change your Activation settings for example when you use a trial code and now you have received a permanent code you need to go to Tools gt Reset gt Reset Activation The next time Investigator 3 opens the Activation window will appear and you can change your code The second option is to get an activation key When selecting this option a new window opens see Figure 3 3 Activation Dialogs 2 This screen shows you the host id which you will need to receive an activation key You can email this host id to Governors support governors nl or copy it to clipboard and email it then We will then send you a trial key or an activation code depending on whether you bought a license or not 11 Investigator 3 Activation TO P SET GOVERNORS 1 Choose activation type Select an activation type from the drop down below If you req
29. ators The colored graphic shows the Investigation Planner in its typical form so that users are aware of its usual appearance Behind the colored graphics you will see that the Investigation Planner has been recreated as an interactive user interface for the purposes of the program Click on the Planner to go to the digital format of the planner visible in Figure 10 1 Investigation Planning Card You can choose to hide this picture in the future by selecting the Do not show this again option Figure 10 1 Investigation Planning Card The investigation planner is broken down into six categories 33 e Technology e Organisation e People e Similar Events e Environment e Time As you can see the first letters of these words make the word TOP SET The meaning of the Planning Card is to plan your investigation taking into account the different categories The indicators in the lists are reminders The indicators are there merely to stimulate discussion and to foster an open minded in the investigator Four of the categories have a more detailed list of indicators underneath the main heading Users can go through the list and make actions on the indicators they think or have a feeling that might have played a role in the causation of the incident Double click on any indicator to add an action to the Planning Action List using the Action Planning Issue Editor see Figure 10 2 Investigation Planning In this editor you can define th
30. cefield Major I before the incident E Technology Power amp Energy Find out what power and energy comes 4 Buncefield Major I across with the processes that are executed ui Jor EI Organisation Management Find out how the management hierarchy Supervision system is built CE Organisation Resources amp Find out what were the resources Finance concerning the operations EM People Skills amp Training Find out what training is required to do the job and what training the employees Buncetield Major I EM a Previous Figure 10 3 Planning and action list To group actions e g by Person Responsible e Grab the Person Responsible title bar e Drag it to the dark blue box at the top of the list Investigator 3 will automatically group your actions according to the people responsible for those actions e Click on the plus or minus nodes to expand or hide the details under each item in the list e You can Preview amp Export or Print out these organized actions by using the print buttons on the toolbar Follow the same steps above to arrange by the other available categories To filter items e Arrange the items in the list the way you desire i e by Person Responsible e Inthe title bar of each category there is a little pin icon 36 Click on the pin and you can filter your results For example you can use the pin in the Person Responsible title bar
31. d e Special version for corporate networks no installation needed To help our corporate customers we have designed a special version of Investigator 3 that does not need the NET framework to be installed This special version of Investigator 3 needs no installation just open the zip file copy the contents to your Desktop or other suitable folder then double click the Investigator 3 program icon to begin To install the software e Click on the download link or open the software from your memory stick or CD e A download window will appear that gives you the choice between running and saving the installer e Click on Save lel to save the installer on your computer otherwise click run Save the installer on the location of your choice It is advised to save it on your desktop so that it can easily be found e When you are manually installing the software with the zip file first extract the zip file and save it on a location Open the software then by clicking on the icon e When the download is completed click run the Investigator 3 Setup wizard window will appear now e The installer will offer to automatically save the software on a prefixed location namely C Program Files TOP SET Governors Investigator 3 You can change this location if you want e The software will be installed now e Open the software from the location where you saved it by clicking on the icon You will be presented with the Investigato
32. e etc The following toolbar buttons apply to the analysis sections Copy To Clipboard Export Metafile Mm BRF Profile py P py EXP Copy to Clipboard Copy the whole diagram or copy a selection to clipboard to be able to paste to other applications Export Metafile To export a picture emf of the diagram BRF Profile Basic Risk profile an overview of all the BRF s only applicable to the Tripod Diagram Undo Redom AU A Undo Undo all you past actions Ctrl Z Redo Redo all your actions Ctrl Y Letter size Increase and decrease letter size 20 Las Actions Layout y Pan Options Actions All the actions that apply to the item that is selected Layout Layout the children of the selected item Ctrl L Pan Pan option to be able to move your diagram around Options Increase or decrease the diagram and item size oom S H F a Zoom Lock Fit Show All Hide Causation Paths Hide Balloons Zoom Zoom in and out in your diagram Lock Lock the zoom level Fit Bring the diagram back to a full overview Show All Show all the hidden items Hide Causation Paths Hide the causation paths in the diagram only applicable to the Tripod Diagram Hide Balloons Hide the narrative and recommendation balloons Preview amp Export and Report Toolbar Ad 100 2144 a i 1 Document Map Show the Document Map next to the report or not 2 Search Use the Search functionality 3 Print
33. e action that needs to be done with all the additional information like who has to do it the due date priority etc You can assign the action to an individual add a priority and due date and mark it as complete If necessary you can add a new individual to the investigation team The box at the bottom of the editor is to put the investigation findings You can fill these in later when you have the answers to the questions of the planning items after the investigation 34 ES Investigation Planner E Planning Action List Here you can create a number of planning or action points Click a relevant item from one of the lists or select one of the buttons on the right to create a new planning issue or action point You may also enter points directly in the table below Die Reagan RAT RE 1 Equipment amp Maintenance 1 Management Supervision 2 Buildings amp Structures 2 Culture and Morale 3 Vessels amp Pipework 3 Methods amp Procedures 4 Transport amp Vehicles 4 Safety Controls Systems 5 Operations amp Processes 5 The Law Codes of Practice 6 Operating Instructions 6 Contractors amp Others 7 Materials amp Chemicals 7 Resources amp Finance 8 Power amp Energy 8 Planning g Design amp Layout 3 Procurement amp Purchasing 10 Other 10 Qualrty 11 Other ene L Injury amp Potential Injury Matural Effects 2 Activities amp Tasks Pollution amp Contamination 3 Knowledge amp Decisions Genera
34. e the main incident description in the report so the text should cover the incident in as much depth as you think will be required 7 3 People Involved Tab On this tab you will enter information about all of the individuals with some involvement in the incident see Figure 7 3 People Involved Tab There are two tables one for the Investigation Team and one for the People Involved in the Incident 1 Investigation Team ap Add XK Remowe Click the Add button to create a new Person 2 People Involved in Incident Unwed Te Company Name cetegoy E Click the Add button to create a new Person Figure 7 3 People Involved Tab Investigation Team e Click the Add ar button to add a new team member and to fill in all the information about that person e Show if the person is a team member e Attachments can also be attached to the person see below 26 People Involved Click the Add SF button and choose which category the individual you wish to enter details about belongs This will bring up the New Person dialog box Individuals can be added in four categories Injured Person Witness Team Member or Other Injured Persons In the New Person dialog box you can enter details about any people injured as a result of the incident Besides being able to enter personal information about each injured person you can use the Injury Details tab to thoroughly document injuries You can fill in details about t
35. ection 1 To group the Recommendations table e g by person responsible e Grab the Person Responsible title bar Drag it to the dark blue box at the top of the list e Investigator 3 will automatically group your actions according to the people responsible for those actions e Click on the plus or minus nodes to expand or hide the details under each item in the list e You can Preview amp Export or Print out these organized actions by using the print buttons on the toolbar Follow the same steps above to arrange by the other available categories To filter the Recommendations table e Arrange the items in the list the way you desire i e by person responsible e Inthe title bar of each category there is a little pin icon e Click on the pin and you can filter your results see Figure 14 2 Recommendations section 2 53 e Use the Preview amp Export button in the toolbar to export you selection of the list or print it This is useful for providing people with specified lists to assign actions to group by date etc S Recommendations MASA Summary List of Recommendations Enter your Recommendations in the table below You can group sort and filter by any column Only displayed Recommendations will show in the Preview Print a ton Drag a column header here to group by that column Ref Code Recommendation Person Responsi gt z iori Complete Edit E Training of personnel in mo
36. ecucsussussussussussussessesseesecseeueeuecucescsucsucsucssseeseeseeseeseeneenes 14 SECO SORDO AO rc s la 15 Step EA ccccccccssesssssssscsssssssssssesesssssessessessessecsscsccsssussucsussussussussusscsessessecuccuccucsussucsussussussussessessessesseeueesecuccucsucsucsucsesseeseeaeeseeseeneenes 15 Step 4 A 15 A2 TRE RIPON TO EIT ANALYSIS METHOD casero cectes cease eceseesencocencsesestararceaceescasateacacceenert ced aceenesacnetexesexereatasstoreeduasnrcecees 16 5 INTRODUCING INVESTIGATOR 3 cvccosccscsesesscecavcczgucarscsacssvnasesseeveecscaxseavecsancsorcssunsgueesnanseceneadecespveseseeseeseeexsiess 17 Oo TOP MENUS S amp S TOOLBARS ocni n E A EE EEA 19 eA E a E ai 19 O PP o An 20 Preview amp Export and Report Toolbar assistance 21 7 SY INCIDENT DETAILS i osgeseccccssccescassevsssasasccsscsccovivnsssussenssceassenesteasasesessceaaceasseseaatsnnsssesectsscenssaqusseadesscetasasecets gt 23 EL BA ORATION TAB raros 23 io cent east acesd dove deed ergo EEEE EE E S 24 A eau A E E AA 24 o on 24 La DEATEDINFORMAMON TAB sata 25 WAVE AG CIO PORO PoUo Uo o po re tee 25 What Were the Glo hiciec 0 2 a acy sra ropa tad 25 Deto ed DEST Pron of MNAE anio 26 Ls PFOP INVODI D TAB cre E ee eee ee E A eee ees 26 Inves gaon Mio 19 eese o OS SECO EIA 26 AN A 27 ANAIS ona cada 27 o E A RA 27 Adding images and other attachMentss cccssssssssssssssssssessessssessssssssssssssessssssssssssescsessecsucsucsssessessessessessees
37. ed until the root causes are known Step 4 Reporting All of the information that the user enters into the software is automatically forwarded to a report which is set up in a standardized format The automatic creation of the report saves the user from having to write a report about the investigation and its findings from scratch as would be the case if they were carrying out a paper based investigation 15 4 2 The Tripod Incident Analysis method Investigator 3 contains a full Tripod Beta Incident Analysis implementation Tripod Beta distinguishes itself from other incident analysis methods through the Human Behavior model that is used to analyze the reasons of failure of a Barrier The Tripod Beta Analysis looks at what caused the sequence of events in an incident The aim of the analysis is to show e What was the sequence of events e How the incident happen what barriers failed e Why these barriers have failed The core of a Tripod analysis is a tree diagram representation of the incident mechanism which describes the events and its relationships The Event in a Tripod Beta Diagram is the result of the Hazard acting on an Object A Barrier is something that s preventing the meeting of an object and a hazard When such a barrier fails a causation path is made to explain how and why this happened The Tripod method presumes that incidents are caused by human error which can be prevented by controlling the working environmen
38. ed zipped Folder ha 63 4 Download the file 5 Open the zipfile double click icon 6 Extract the zipfile 0 of download php from www governorsmansion nl Co download php from www governorsmansion nl D Estimated time left Download to Transfer rate Open Folder Investigator al ll sa CES Investigator 3 23 p Search E Bi Organize v 2 Views El Extract all files Favorite Links Compressed sre Dropbox E Documents Re Music More Folders a HE Desktop b ag Estella Groeneweg gt Ji Public gt 1 Computer gt y Network gt Control Panel E Recycle Bin gt de dvd irc A Investigator 3 1 22 dy Investigator 3 2 3 7 Select a destination for the file Select a Destination and Extract Files Files will be extracted to this folder C Users estella Desktop Investiga Show extracted files when complete 64 10 Open the software from the saved location Favorite Links Folders EZ Desktop Estella Groeneweg de Public jE Computer EP Network Control Panel E Recycle Bin P dvd irc i Investigator 3 2 3 4 Investigator 3 1 22 de Investigator 3 2 3 J Investigator 3 2 3 11 Run the software Open File Security Warning The publisher could not be verified Are you sure you want to run this software La Name tella Desktop Investigator 3 2 3 Investigator exe Publisher Unknown Publisher Type Application From G
39. eeasescsecsucsucsessesseeseeseeseeseeneenees 27 8 E TERMS OF REFERENCE ocioso occ AA AAA iaa 29 Q 2 REPORT INTRODUCTION cc naaa 31 91 REPO TINTA UN oca 31 22 A A 32 10 TOL INVESTIGATION PLANNER 33 10 2 PLANNING ACTION US 35 11 A DEVELOP THE STORYBOARD sons ip ts 38 11 1 OVERVIEW amp ATTACHMENTS reed 40 12 13 131 ROOTCAUSE DIAGRAM ansiada N A aiii 42 Building a Root Cause Diagram wu cesecsesesssssssssssssssessssessssessssessssessssessesesussessssesucsesessesessesssescsesecsesesesessesessesessesessesesseseeseaeeseaeeneaes 43 Lavon ODO AA 43 e NS pt sts gece eran seeders tuscan sc nae ctecaeais ts aceasta aw setae eee eee 44 MONTI SOON Slap 44 Lal TIPO ME ODIA ir 45 TOS tar YOUR TID OG OQ article eed dadas 46 Toad BAT Or Ona CAO DO at 46 To add a BRF code to a Latent FUI arado 47 LVU OON e E E ch cettecac tea cus de ccates ea tonceceacatacateaenas coeesaeeaeeeeeancaet eens 47 e 48 AP e 48 G ge OPC O 48 IE NOT A 49 BAO occa nese asa azza ase sezzeseaze ezce ezceezzezeuzezeszezeszezeazezeazezezzezeuzezsuzezsucezeuzezsuze euze suze suze eaze euze suze suze sane nsuzensunensunentates 49 133 ANALYSIS DIAGRAMA 49 13 3 1 Item Properties Figure 13 6 Properties WindOW ccsesssssssssessssesesssssssesessesssecsesesssessssessssesesseessseensseeseseeeeseenees 49 13 3 2 Overview Figure 13 7 Overview WINGOW ccsesessssssessessseesessssesessssesesssesssussesesuesesesucsesesueseseaeseseaneseseensseseensseaeenss 50 13 3 3 Attachments
40. eport Buncefield Incident Investigation Endis Crocnoez a cast pote Enrotqaton Beerd Wednesday October 14 2009 a Page 2 of 21 Words 2 781 English United States Figure 15 2 Word Report 58 Attachment How to install Investigator 3 MSI 1 Click on the download link 2 Click on Save 3 Save the installer Investigator 3 Beta Downloads Version 3 2 rev 3 Investigator 3 2 rev 3 executable 149m8 35 in a zip file for manual installation Investigator 3 2 rev 3 release notes 175 0 in rtf includes the changelog File Download Security Warning Do you want to run or save this file Name Investigator 3 2 3 msi Type Windows Installer Package 15 4MB From Www governorsmansion nl While files from the Intemet can be useful this file type can ry potentially harm your computer f you do not trust the source do not run or save this software What s the risk Save As OU o HE Desktop gt X 4 Search W Organize E Views BY NewFolder Favorite Links Name Size E is Estella Groeneweg More Folders v 1 Public 4 HZ Desktop A 4 Estella Groenewe gt Je Bluetooth Soft D Computer Ji Contacts j 5 gt I Desktop gt ES Documents A Network 4 Downloads lt lt e The Office Li The Office Type Date modified dvd irc File Falder Filename Investigator 3 2 3 w Save as type Windows Installer Package a Hide Folders
41. ere as the standard method Off course you can alter or remove this text if you like To edit the Method of Work e Simply edit the text as you wish the existing text is just for guidance e Ifyou wish to start again click Reset to Default Text e Be sure to save your work using the Save lel button so that you do not lose your edited text e Add attachment in the Attachments window next to the Report Introduction section for help see 13 3 3 Attachments If you wish you can edit the default text so that it appears as you wish it to each time you use the application e Click on Edit Default Text to edit the existing text e Edit the default Method of Work in the Default Method of Work window so that it appears as you wish it to e Ifyou wish to start again click Reset e Once you are finished click OK e You must restart the application for the edited Method of Work to be displayed If you wish to reinstate the default text e Click on Tools then Reset User Settings e You must restart the application for the default Method of Work to be reinstated 32 10 Plan Investigation In this section you will plan the investigation and investigate to gather evidence or data 10 1 Investigation Planner The Investigation Planner see Figure 10 1 Investigation Planning Card is a representation of the TOP SET Planning card used on TOP SET courses and worldwide by professional investig
42. he field to activate the drop down menu e Under Miscellaneous you can choose whether each event should be included in the report the events you select from the Storyboard will be shown in the Timeline Sequence of Events Leading to the Incident subsection of the report 11 1 Overview amp attachments e To aid in navigating the different items sticky notes it is possible to switch between the attachments window and the overview window You can find these windows underneath the Properties window at the left bottom side of the screen The overview window is used to navigate the entire storyboard with It shows you a bird s eye view of the entire Storyboard It is a good way to navigate a complex Storyboard and zoom in on portions you wish to edit or move To select a portion of the Storyboard use your mouse to drag the green box over the area you wish to focus on The Storyboard will snap to the selected section Use the Fit button on the toolbar to show the whole Storyboard again To find out how the Attachment window works see 13 3 3 Attachments 40 12 i Identify the Immediate Causes When you are planning to do a Root Cause Analysis the Immediate Cause Wizard can help you identifying your Immediate Causes This dialog box will appear in the lower right hand corner of the Storyboard window This wizard prompts you with relevant questions trying to find the immediate causes of the incident You go through the wizard wi
43. he nature of the injury part s of the body and the source of injury Witnesses In the New Person dialog box you can enter details about any witnesses to the incident Other Persons Involved In the New Person dialog box you can enter details about anyone else involved in the incident or investigation that doesn t fall under the earlier categories In the New Person dialog box you can also add notes and drag and drop images and other attachments for example Word documents using the Attachments area Attachments In the People Involved section you can add attachment to the u persons see Figure 7 4 Attachments a g IM Adding Notes ul Click the plus symbol SF icon to create a new note Interview Provide the note with a title and add your note text in Person X the field marked Notes or copy and paste your note text from another document into this field NB Please by MARE note that it can be very useful to add interview notes in this way The text you enter into this field can be shown in the report or left out by clicking the Show in Report checkbox You can then move back to a list of the notes images and attachments you have added by clicking the small arrow icon Adding images and other attachments Figure 7 4 Attachments Adding images and other attachments by locating the relevant file on your computer You can add images and other attachments for example Word d
44. he same time or copy the selection to clipboard When you hit the Copy to Clipboard button only the selection will be copied and you can export for example to PowerPoint You can collapse and expand you Tripod tree by clicking on the little yellow minuses in the upper left and right corner of the items The right minus will collapse all the items at the right side of that item the left minus collapses the children of the item Then the minuses turn into plusses and you can expand your selection again When right clicking on an item you can choose to hide the child or parent elements This way you can hide or show different parts of your diagram to be able to present it step by step Right click options General When right clicking on any of the items you get a number of options see Figure 13 5 Right mouse click menu Tripod Add Latent Failure Add Recommendation When right clicking on an item the first options are to add the o next items that can be added Add Narrative ms E Delete The next general option is to add a Recommendation and a Narrative When adding a Recommendation a new window opens where you can fill in all the information about that recommendation like who Is responsible the priority the due date etc A blue balloon with the recommendation code will A then appear on the item In the narrative balloon you can place comments or extra information Hide Child Elements Hide Parent Elements Layout Immediate
45. igator 3 saves the location of your document You must save these attached files separately 28 Terms of Reference Particularly in bigger more serious incidents the Terms of Reference can be useful to make certain appointments For example who will be on the team what methods are used and how we describe the incident In the Terms of Reference see Figure 8 1 Terms of reference information from the Incident Details section is automatically inserted where relevant into the upper portion of the text Then a basic remit for the investigation is displayed You should edit the Terms of Reference to suit your own investigation Terms of Reference It is important particularly in larger more serious investigations to agree the Terms of Reference with your team sponsor or client By doing this you define what has to be done Investigation into the New Investigation on 14 October 2009 at 14 14 18 An investigation is required into the circumstances leading to and the causes of has been appointed team leader Other members of the team are New Person Health and Safety representatives from shall form part of the team The remit for the investigation is to a Determine the sequence of relevant events leading up to the incident b Identify the Immediate Underlying and Root Causes c Make suitable recommendations SMART actions to prevent the same or similar occurring again d The report should be supported by photographs and
46. ion location 9 Install the software 10 Open the software from the saved location is Investigator 3 e e e e aH Select Installation Folder The installer will install Investigator 3 to the following holder To install in this folder click Next To install to a different folder enter it below or click Browse Installing Investigator 3 Investigator 3 i being installed Folder C Program Files TOP SET Governors nvestigator 3 Install Investigator 3 for yourself or for anyone who uses this computer a Everyone 5 Just me Please wait B Organize yf Views Cancel di lt Program Files TOP SET Governors Investigator 3 I Favorite Links Dropbox IF Documents 12 Music More Folders di Microsoft Visual Studio di Microsoft Works dJ Movie Maker Jo MSBuild Ly MSN Messenger Le QuickTime P Reference Assemblies a Roxio di ShoppingReport J Sigmatel de Synaptics de System Search Dispatcher do TOP SET Governors de Investigator 3 1 TOP SET Governors BV A 2 items v Slide Show a Wi Compatibility Files Date taken Tags Investigator 61 11 Run the software and choose how you want to run Investigator 3 Activation 7 TOP SET GOVERNORS Investigator 3 the software This product is not currently activated or about to expire Please follow the instructions below and contact your softw
47. l Conditions 4 Attitude Behaviour Location 6 Health amp Fitness Flora Fauna 7 Emotional State Biological Factors 8 Communications 2 3 4 5 Housekeeping 5 Skills amp Training 6 7 B 9 Radiological Factors 9 Personal Protection 10 Error Inducing Conditions 10 Other 11 Other E4 Show TOP SET Planner Image Figure 10 2 Investigation Planning Technology Organisation People Similar Events Environment Time Sequence and History of Events r Changes and Differences Defeated Controls or Barriers r Who saw what Action Urgent Action Next On the right hand side of the page there is a box with Other Planning Items and Action Points Here you can add actions to your investigation that may not be represented in the given lists Continue to do this to build a Planning Action List of things to investigate You can still open the TOP SET Planner Image by clicking on the Show TOP SET Planner Image button 10 2 Planning Action List In this section a Planning Action List of all the actions you defined in the Investigation Planner are listed see Figure 10 3 Planning and action list You can arrange the items in the list by grouping them by category or by filtering them according to the information you have entered under each category You can move the columns simply by grabbing the title bar with you mouse and moving the column to the position
48. matically based on all the information you provided in the program see Figure 15 1 Report On the left side of the screen there is a Document Map you can use to navigate through your final report You can click on the plus or minus nodes to expand or hide the subheadings To adjust settings for the report like font size or select certain options go to Tools gt Options gt Report or Word Report Investigator 3 3 2 rev 6 Report New Investigation File Report View Background GoTo Tools Help New C Open sve 22 MIE By YA s Alo AE a lar A Document Map r pa Contents A Terms of Reference Method of Work Incident Details g The Incident Findings of the Investigation L Appendix A New Investig Terms of Reference A Report Introduction EX New Investigation Investigator 3 Report Plan Investigation Report version Draft 1 0 Autho s Develop StoryBoard Analysis a A Immediate Cause Wizard o 3 a t Tripod Method Diagram 14 October 2009 Conclusion a 4 Recommendations Executive Summary Current Page none Total Pages 0 Zoom Factor 85 Figure 15 1 Report Investigator 3 creates the following chapters in your report e Contents e Terms of Reference e Discussion of Findings e Conclusion e Recommendations e Introduction e Method of Work e Investigation Team 56 e The Incident e Description of the Incident e Consequences e Detailed
49. nitoring Estella Groeneweg Blanks Redesign of tanks for making release of fuel and formation of vapour Estella Groeneweg Non blanks impossible m Improving or creating emergency system Management Improving maintenance procedures Management i Better monitoring of tanks and pipes Estella Groeneweg 25 08 2009 Normal Create workable procedures Management 06 10 2009 High Creating detection system of gas levels Estella Groeneweg 16 07 2009 Normal Increase awareness of safety with management Estella Groeneweg 24 10 2009 Urgent W LS USL y y y LS 00 00 0 0 Figure 14 2 Recommendations section 2 13 4 Executive Summary When clicking in the Next button or clicking on the tab you go to the next section the Executive summary see Figure 14 3 Executive Summary The Executive summary section consists of two parts Discussion of Findings and Conclusion These are basically free text fields to write you findings and discussion You can also copy paste text from Word or other applications Again you can use the Preview amp Export or Print buttons in the toolbar to export or print this section 54 E Recommendations El Discussion of Findings Discuss your findings in the box below Conclusion Write your conclusions in the box below Figure 14 3 Executive Summary 55 When you click on Report in the navigator your investigation report will be created auto
50. nu see Figure 6 2 Options ES Overview Options that can be changed are Diagram Storyboard General Application appearance currencies files and image settings Diagram Diagram size and font layout options Storyboard Time period sizing categories actors hala a Report Fonts and watermarks na Word Export Report options image size options Figure 6 2 Options Overview Terminology Terminology options In the Help menu you can find the Help file Contents the newest Investigator 3 download links under Online and the option to Collect the error report 19 Menu shortcut keys Ctrl N New File Ctrl O Open File Ctrl S Save File Alt P Go to People Involved Alt F Go to Menu gt File Alt E Go to Menu gt Edit Alt D Go to Menu gt Diagram Alt V Go to Menu gt View Alt G Go to Menu gt Go to Alt T Go to Menu gt Tools Alt H Go to Menu gt Help 6 2 Toolbars Throughout the software you will find the same toolbar Only the Analysis Diagram section has other new buttons in the toolbar The usual New Open and Save buttons are visible here see Figure 6 3 Basic Toolbar The next two buttons are Preview amp Export and Print With the preview amp i IRA AA export button you can view how your File Edit GoTo Tools Help work will look in the report In this n window you can also export the overview E a n aaa to other applications like Word Excel Figure 6 3 Basic Toolbar and Adob
51. o ainia 56 EU ES ZO Rd detected 58 3 Installation Instructions 3 1 Installation There are three types of download options that you can choose from whether you download the software from the download page or from a memory stick or CD Most of the time you are provided with these three options e Investigator 3 Installer msi for automatic installation This installer will guide you through the process of installing Investigator 3 on your computer This is the option most people should pick Just download and double click this file to begin To get an extensive explanation on how to install with the Investigator 3 installer look at attachment A e Investigator 3 Manual Installation zip for manual installation If you would rather not use an msi file you can download a zip file with the program Just open this file copy the contents to your Desktop or other suitable folder then double click the Investigator 3 program icon to begin To get an extensive explanation on how to install Investigator 3 manually look at attachment B Note You will need to extract the software from the zip archive before it will run correctly If you receive an error message unhandled exception please check to see if you have done this If for any reason the above options are not suitable please download Investigator 3 with the NET framework already included As its name would suggest this does not require the NET framework to be pre installe
52. o to Develop Storyboard F7 Go to Analysis Diagram F8 Go to Recommendations amp Executive Summary F9 Go to Report F11 Full screen Alt F4 Quit application 18 Top menus amp Toolbars 6 1 Top menus 2 3 rev 5 Start New Investigation Within Investigator 3 the top menu bar remains available Investigator 3 3 throughout the program Most menu items are similar to File GoTo Tools Help the standard Microsoft Office tasks such as new open _ New Open Ca save special characters help and about see Figure 6 1 Top menus Figure 6 1 Top menus In the File menu consists of the options to manage your files like New Open Save and Save as But also the option Recent Files which will give you an overview of all the files you recently worked in The Go To menu items are the third way of getting access to your workflow and features the same elements as the navigator All the sections of the software are accessible in this menu Within the Tools menu you can select or change all the options in the software The first option Show Navigator is to show or hide the navigator on the left hide side of the screen It is also possible to select special characters from the default windows special character pallet In the Tools menu you can also reset settings reset the Investigator 3 setting reset the windows and toolbars and reset the activation You can also edit several options for Investigator 3 from this me
53. ocuments by clicking on the small open folder icon You can then select an image or other attachment You can rename it in the Title field and elect whether or not the attachment should be shown in the report by clicking the Show in Report checkbox You can then move back to a list of the notes images and attachments you have added by clicking the small arrow icon Adding images and other attachments using drag and drop You can add images and other attachments by physically dragging the relevant file from its location on your computer into the Zi Attachments field using your mouse You can then move back to a list of the notes images and attachments you have added by clicking the small arrow E icon e Using the Link icon If you have added an attachment previously to one individual s details and you wish to add the same attachment to another individual s details you can do this by using the Link icon Use the small arrow icon next to the icon to see the attachments you have already added elsewhere shown as a drop down menu NB Please note that only plain text can be viewed in the report This means that only text that has been copied and pasted into the Notes field can be viewed in the report Pictures can also be viewed in the report However it is not possible to view attached documents for example Word documents in the report Your investigator 3 file will than get inconveniently large Invest
54. ottom left of the table When clicking these buttons a new window opens see Recommendations W Executive Summary List of Recommendations Enter your Recommendations in the table below You can group sort and filter by any column Only displayed Recommendations will show in the Preview Print oF Add x Remove Drag a column header here to group by that column Ref Code Recommendation Due Date Person Responsible Priority Complete Edit Click the Add button to create a new Recommendation Figure 14 1 Recommendations section 1 where you can fill in all the information about your recommendation the person responsible priority due date and whether it is completed or not All the recommendations will appear in a table You can arrange this table by name person responsible date and priority You can add or remove recommendations on this screen by clicking on the appropriate buttons 52 Recommendations MAS EN List of Recommendations Enter your Recommendations in the table below You can group sort and filter by any column Only displayed Recommendations will show in the Preview Print al Renae Drag a column header here to group by that column FRe Code Recommendation bue nate pesones Prony Compete Edt Recommendation Editor ca Recommendation Completed By Whom y Add New Person Priority Normal Due Date 14 10 2009 a Notes Remarks Figure 14 1 Recommendations s
55. r 3 Activation window 3 2 System Requirements To install and run Investigator 3 the target system must meet the requirements set out in this section Note that if your system is kept up to date using Windows Update it will most probably meet all of these requirements except the NET framework but they are listed here for completeness Supported operating systems are Windows 2000 Windows XP Windows Vista and Windows 7 You must be running Microsoft Internet Explorer 5 01 or later You must have at least 128 Mb of physical memory 256 Mb is needed to run Investigator 3 comfortably You must have one drive with 50 Mb of free disk space You must have a minimum screen resolution of 1024x768 and a color depth of 16 bits but considering the graphical nature of Investigator 3 the bigger your screen the better Investigator 3 can interoperate with all Microsoft Word and Excel versions The supported Visio versions are 2000 2002 XP 2003 and 2007 In order to run Investigator 3 needs to have the NET Framework 2 0 or higher installed on your PC This is discussed in the next section 3 3 The Microsoft NET Framework What is Microsoft NET Microsoft NET is the Microsoft strategy for connecting systems information and devices through Web services so people can collaborate and communicate more effectively NET technology is integrated throughout Microsoft products providing the capability to quickly build deploy manage and
56. re 13 7 Overview window again Attachments Evidence Event Click the plus ar button to create a new note Add a new note or drag and drop images or other attachments here Provide the note with a title and add your note text in the field marked Notes or copy and paste your note text from another document into this field NB Please note that it can be very useful to add interview notes in this way The text you enter into this field can be shown in the report or left x ie O se Mi Es out by clicking the Show in Report checkbox You can then move back to a list of the notes images and attachments Gij Attachme Aa Overview Figure 13 8 Attachments window you have added by clicking the small arrow button 50 Adding images and other attachments Adding images and other attachments by locating the relevant file on your computer You can add images and other attachments for example Word documents by clicking on the small open folder icon You can then select an image or other attachment You can rename it in the Title field and elect whether or not the attachment should be shown in the report by clicking the Show in Report checkbox You can then move back to a list of the notes images and attachments you have added by clicking the small arrow button Adding images and other attachments using drag and drop You can add images and other attachments by physically dragging the relevant file from it
57. s a picture emf file There is also a button in the toolbar lal Export Metafile you can also export your diagram by clicking at the Preview amp Export button in the toolbar A new window opens with an overview of your diagram You can export the diagram with the export La button e When clicking f11 you change the window toggle mode Press it once you get full screen press it twice the windows and navigator disappear Layout options e To add or edit text double click in the Cause to zoom in and add or edit text Click in the background of the Storyboard to zoom out again or press enter To do this you have to select the option Enable single click editing of shapes in Tools gt Options gt Diagram e When you drag and move an item the children of that item will move as well This makes the customization of the layout easier When you want to move just one item press the alt button on your keyboard while moving the item e To redraw the layout of the diagram automatically right click on any item and click on the option Layout Immediate Children or Layout all Children You can also click on the Layout button in the toolbar e You can modify the sizes of the sticky notes by selecting the Free sizing of shapes option in Tools gt Options gt Diagram You can also modify the text size by using the big A and small a buttons in the toolbar e You can color code Causes using the drop down menu nex
58. s location on your computer into the Attachments field using your mouse You can then move back to a list of the notes images and attachments you have added by clicking the small arrow button Using the Link button If you have added an attachment previously to one individual s details and you wish to add the same attachment to another individual s details you can do this by using the Link button Use the small arrow 2 button next to the icon to see the attachments you have already added elsewhere shown as a drop down menu Saving the attachments to disk Use the small Save ll icon to save your attachments to a location of your choosing NB Please note that only plain text can be viewed in the report This means that only text that has been copied and pasted into the Notes field can be viewed in the report Pictures can also be viewed in the report However it is not possible to view attached documents for example Word documents in the report You must save these files separately 51 14 J Recommendations amp Executive Summary 14 4 Recommendations In this section of the software the recommendations made by you or your team are displayed The recommendations that are added in the Diagram section are automatically added in this section But you can also add new recommendations here by using the Add SF button You can also add a new recommendation by clicking the little plus button at the b
59. t The Causation Path displays this by starting with the Active Failure of the barrier then under what Precondition or in what contextual state this happened and at last the Underlying Failure of the barrier The aim of Tripod Beta is to uncover the hidden deficiencies in an organization the Latent Failures These can be classified into eleven Basic Risk Factors BRF s these are categories that represent distinctive areas of management activity where the solution of the problem lies All the items of the Tripod Diagram are visible in the basic Tripod tree diagram in Figure 4 2 Tripod tree Latent Failure Precondition k Active Failure Precondition Hazard EJ Failed Barrier Figure 4 2 Tripod tree 16 Introducing Investigator 3 Investigator 3 is a software program for the professional investigation and analysis of incidents It can be used for incidents of any scale Investigator 3 is based on the TOP SET incident investigation methodology and the Tripod method Most of the information in this user manual is also available in the Help section of Investigator 3 The first screen see Figure 5 1 Start page gives the user 43 investigator 3 3 2 rev 5 New Investigation mr the option to start a new investigation or open a saved GoTo Tools Help one Investigation x Start Incident Details Terms of Reference Report Introduction ied Plan Investigation A Develop StoryBoard Anal
60. t press F9 and click on the company logo to update the contents You can also click on the Export e 7 button in the toolbar to export your report to different applications You can export the report as a PDF file HTML file RTF file Excel file etc You can also send your report as an email with the email button in the toolbar Again you can choose from different formats Buncefield investigation V3 Compatibility Mode Microsoft Word Ea ome Inse Pag out References Mailings Revie n Y i Jt z 2 vial BA 20 Fr P i ind f i Book Antiqua vid Ara ON 3 EE daBbCcl AaBht AaBbC AaBbCi AaBbCc AaBbCcl A ac B ZI U abe x Xx Aa ay AY 2222 t Ari Emphasis Headingi THeading2 THeading3 T Normal Strong gt Select esy K i Paste E Styles m Editing J Format Painter Clipboard a Font E Paragraph Ay am s aea ot Titties EEE Br Brenda EXSgrr re gl Contents Contents Terms of Reference Discussion of Findings Conclusion Recommendations ee Method of Work Investigation Teang The Incident Report version Draft 1 0 Description of the Incident Whathappened Consequences Detailed Description of the Incident y d Whens Happened Where Happened People Involved 4 Injured People a Other People Findings of the Iuvestigati Timeline Sequence of Events Leading to the Incident A Appendix A Investigation Diagram Appendix B Injury Reports Authors Investigator 3 R
61. t to Color in the Classification section Click in the field to activate the drop down menu e To select a particular part of your diagram drag a square with your mouse over the items you want to select The selected area will then be highlighted This is also a way to increase or decrease letter sizes 43 of the text of the items at the same time or copy the selection to clipboard when you hit the Copy to Clipboard button only the selection will be copied Presentation options e When you have built a big tree and you want to present it to an audience you do not want to show the complete tree all at once Therefore we made it possible to hide certain parts of your tree to be able to build it step by step Right click on a cause and you see the options Hide Child Elements and Hide Parent Elements With these options you can hide or show the child and or parent element attached to the selected item e To select a particular part of your diagram drag a square with your mouse over the items you want to select The selected area will then be highlighted When you hit the Copy to Clipboard button only the selection will be copied and you can export for example to PowerPoint e You can collapse and expand you Root Cause tree by clicking on the little yellow minuses in the upper left and right corner of the items The right minus will collapse the parents of the item the left minus collapses the children of
62. th the button Next and by answering Yes or No to all the questions When answering yes you will identify what that immediate cause is These immediate causes will then automatically appear in your Root Cause Diagram You can exit the Wizard at any time by clicking the cross icon in the top right of the Immediate Causes Wizard window or by answering No to further questions and finally Finish to complete the Wizard It is recommended that you enter no more than three or four events into the Wizard so that it is used maximally and does not become laborious Immediate Cause Wizard TOP SET GOVERNORS Welcome to the Immediate Cause Wizard This Wizard will help you to tease out the immediate causes of the incident Immediate Causes are the things that went wrong or the actions people took that on this specific occasion led directly to the incident The more events you enter the more questions you will get asked Use the cross on the control bar if you want to quit at any point Cancel Figure 12 1 The Immediate Cause wizard 41 13 sa The Analysis Diagrams Analysis Diagram y When clicking on the Analysis Diagram in the navigator you will ANT get the choice between making a Root Cause or a Tripod Beta Diagram see Figure 13 2 You can also make the choice at the start page in the workflow If you want to change your choice ra E f you will have to save a new file You cannot save both an
63. the diagram e To add or edit text double click in the item to zoom in and add or edit text Click in the background of the Storyboard to zoom out again or press enter To do this you have to select the option Enable single click editing of shapes in Tools gt Options gt Diagram e To connect items hover over an item and four red triangles appear in each corner of the item You can use these triangles to draw lines in between items Just click in the triangle and drag a line to a triangle of another item then click and drag to the item to which you want to connect e When clicking f11 you change the window toggle mode Press it once you get full screen press it twice the windows and navigator disappear To add a Barrier and Causation path e Double click on the line between the Event and the Hazard and or the Event and Object to automatically add a Failed Barrier 46 e To adda Missing Barrier and or an Effective Barrier right click on the line You can also right click on an existing Barrier and choose Convert to gt Effective Barrier or Missing Barrier e If you double click at a Failed Barrier the Causation Path will be created working backwards from the Barrier Barrier Active Failure Precondition Latent Failure e After that you can keep on double clicking on the different items Double clicking on an Active Failure will create another Precondition double clicking on the Precondition will create an e
64. the item Then the minuses turn into plusses and you can expand your selection again Right click options When right clicking on any of the items you get a number of options see Figure 13 3 Right mouse click menu e When right clicking on a Cause the first option is to add the Add Cause next Cause can be added J Add Recommendation e When right clicking on a Cause you see that there are Add Narrative several options You can add a Recommendation and a Narrative When adding a Recommendation a new window opens where you can fill in all the information about that recommendation like Ros who is responsible the priority the due date Hide Child Elements etc A blue balloon with the recommendation code will then appear Figure 13 3 Right mouse click menu on the item In the Root Cause narrative balloon you can place comments or extra information Delete Layout Immediate Children Layout All Children Hide Parent Elements e Then there is a Delete option to delete the item 44 e The next options are for the layout of the children items evolving from the selected item of the item e Layout Immediate Children e Layout All Children e The last option is to hide child or parent elements of that particular item Diagram shortcut keys Ctrl F Fit Diagram Ctrl L Layout Diagram Ctrl A Select all Ctrl B Layout all Children Ctrl Z Undo Ctrl Y Redo Ctrl Shift P Pan Ctrl Alt N Hide or Show Balloons
65. tion the barriers on the lines between Event and Object will be flipped turned upside down This way the Causation Paths will go down instead of up to make the layout more efficient e Tripod Causation Path Link Styles choose how you want the lines from the Barriers to the Active Failures to appear You have the choice between Straight Curved and Right Angle 47 e Tripod Diagram Alignment choose how you want your diagram to be aligned Top default the Event appears on top next to the Hazard Centre Children the Event appears in the middle of the Hazard and Object Centre Sub Trees the main trio appears as default the sub trees appear as Centre Children and Bottom the Event appears at the bottom of the diagram next to the Object Presentation options When you have built a big tree and you want to present it to an audience you do not want to show the complete tree all at once Therefore we made it possible to hide certain parts of your tree to be able to build it step by step In the toolbar you find two hide buttons Hide Causation Paths and Hide Balloons When you click on the buttons again the items appear again you can also click on the button Show all To select a particular part of your diagram drag a square with your mouse over the items you want to select The selected area will then be highlighted This is also a way to Increase or decrease letter sizes of the text of the items at t
66. tionally carried out by a team using large AO size paper charts the Planning chart Storyboard chart and Root Cause Analysis chart and Post it notes Here this method of working is recreated using easy to use graphical interfaces that replicate the flexibility of using paper charts and Post its We would encourage that the software is used by a group working in collaboration and in tandem with the paper based method so that the open thinking vital to the methodology is encouraged and enhanced The software acts as a repository for all of the information gathered during an investigation Without the software organizing all of this information would be a cumbersome and time consuming task Furthermore using the software means that the information gathered during an investigation can be easily communicated amongst the investigation team members and to senior staff People in different locations can also work together on the same investigation 13 KELVIN Gmg 4 1 TOP SETO Incident Investigation Methodology TO P SET The TOP SET incident investigation methodology is used by major blue chip clients all around the world It is taught on 1 day or 3 day senior courses held throughout the world and are the basis of several incident investigation products for professional incident investigators Further details are available at www kelvintopset com TOP SET was developed in 1989 to provide a comprehensive incident investigation methodology th
67. uire site activation click Show Groups then select the required group Activation type El This computer Current Host ID SARHQH K 5LW63XRR RAID 25W8Z4MQ 2 Send us your details To receive an Activation Code please e mail us the above details If the Create E mail button does not work with your email program please instead use Copy to Clipboard and manually paste the details into an email addressed to activate topsetgovernors com Create E mail E Copy details to Clipboard Cancel Figure 3 4 Activation Dialog 3 The last option Continue is to run the software in trial mode Choose this option when you did not receive an activation key This option will give you the opportunity to work and evaluate the software for 30 days After 30 days the activation automatically expires 3 6 Network Installation To install the software on a network you first need to create a Windows user group in your Windows domain say Investigator 3 Users Then add licensed Windows domain users to the user group Run Investigator 3 under an Administrator account In the Activation Dialog see Figure 3 2 Activation Dialog 1 upon first start and choose Get an Investigator 3 Activation code In the next dialog see Figure 3 4 Activation Dialog 3 click on the Show Groups button and a list of all User Groups on your domain will show Choose your User Group the one that contains the Investigator 3 users and choose
68. vation Note that you must be a member of the intended group for this to function otherwise access to the software will be denied and the newly entered activation code will not be saved Also note that after changing group memberships users will need to log off and on again for these membership changes to take effect 3 5 User Activation After downloading the software and opening it for the first time you will be prompted with the window visible in Figure 3 2 Activation In the window you get three choices in how you want to activate the software Investigator 3 Activation TOP GOVERNORS Investigator 3 This product is not currently activated or about to expire Please follow the instructions below and contact your software supplier if necessary Activation Status Activation Type Mot Activated Expires Sunday July 27 2008 Run in Trial Mode 7 days remaining What would you like to do Get an Investigator 3 Activation Code Enter Activation or Trial Code Hest gt r Cancel Figure 3 2 Activation Dialog 1 The first option is to enter a new activation key Once you have received your activation key or trial code you can fill the code in this window in If you want to view the host id again you can click on the Advanced button When entering a correct code the activation status will turn green and you can start the software see Figure 3 4 Activation Dialog 3 10 Please enter the activ
69. xtra Latent Failure etc To add a BRF code to a Latent Failure e Once you have added a Latent Failure to your diagram you can select a BRF code e Inthe bottom left corner of any Latent Failure item there is a small drop down window e Click on the arrow to select from the list of BRF codes provided Layout options e To resize shapes select the option Allow free sizing of shapes in Tools gt Options gt Diagram Then little green handles will appear on the items to make them smaller or bigger e When you drag and move an item the children of that item will move as well This makes the customization of the layout easier When you want to move just one item press the alt button on your keyboard while moving the item e To change the color of a line click on it and change the color in the Properties window e To redraw the layout of the diagram automatically right click on any item and click on the option Layout Immediate Children or Layout all Children You can also click on the Layout button in the toolbar e To change the way the diagram is drawn you can change Layout options in Tools gt Options gt Diagram Under the layout section you see different options e Use right angle links select this option when you want the lines from Event to Hazard and Object to appear right angled When deselecting this option the lines will appear straight e Automatically flip barriers when selecting this op
70. ysis Immediate Cause Wizard a Analysis Diagram Conclusion Recommendations amp Executive Summary Report Figure 5 2 Navigator y New E Open TO P SET GOVERNORS After starting a new investigation or opening a saved one Investigator 3 leads the user through a systematic nine step approach which covers the entire investigation process This process is referred to as the Investigation Workflow see Figure 5 3 Investigation Workflow and is presented on the first screen During the process this workflow is also available on the left hand side of the screen the navigator see Figure 5 2 Navigator This menu will stay visible throughout the To get started please open or create a new Investigation E Open program The section were you are Figure 5 1 Start page working in is highlighted in red in the menu You can jump through this menu in whatever order you want Sections can also be skipped The Start button will always bring you back to the Investigation Workflow In the Investigation Workflow you can select your choice between the two analysis diagrams Root Cause and Tripod Beta You can also click on Analysis Diagram in the navigator You will then also be able to make your choice between the two analyses methods The left hand menu is divided in three sections Investigation Analysis and Conclusion 17 Investigation WorkFlow Each step in the Investigation Workflow has its own

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