INVESTIGATION CATALYST
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© 2003 by Starline Software Ltd.

PROBLEM DISCOVERY

Analyze the Matrix entries to discover and define problems disclosed by the process.

General Approach To Problem Definition Task

Start by looking for candidate opportunities for improvement (or problems) by examining one linked event pair or set at a time, until all have been studied. Start anywhere, preferably at the end and work backwards, but cover every pair or set on your worksheet. For each event pair, set or link, ask yourself questions to determine if the event or relationship may be a problem or constraint in the future, and whether it might need to be changed.

Compare with expectations.Ask a series of questions to identify undesired actions or relationships compared to expectations:


Deviations from expectations suggest a problem - either with what happened, or the expectations.

"Can this event or relationship indicate a need for a change, and if so, why?"

The answer to each question may suggest a problem event or relationship,

Use the MOTEL

M O T E L can help you define the problem in terms of its

  • MAGNITUDE: the strength of the influence on the next event, and why did it have that influence;

  • ORIGIN: should that relationship have occurred at all and why did it occur;

  • TIMING: how fast or when it happens or how long it lasts, and why did the timing occur;

  • EFFECTS: who or what it affects and how or when, and why those effect occurred; and

  • LOCATION: where it starts or happens in relation to exposures at risk, and why it occurs there.


When you find an opportunity to improve the process tag it with a Diamond.

Energy Trace and Barrier Analysis

Start with any energy inputs into the process described, and trace the energy through the process, either as it flows through the process or to where it is converted to work, or another form of energy. Don't overlook people as energy sources that do work in some cases. The reference below provides a list of energies that might be helpful.

Then identify the barriers or controls that keep the energy flowing where it is desired, and consider where or how it might overcome or "breach" each barrier, or where it did so in mishaps.

For more information about this analysis method, click here.

When you identify a problem, restate it in terms of what needs to get done to eliminate or control it. The wording of your problem statement has the effect of establishing the objective for any action.


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