Software Manual BlackBox 1.3
Software Manual BlackBox 1.3
Software Manual BlackBox 1.3
Please note that this documentation is preliminary and subject to change without notice. The latest
version of this document can be obtained via Governors (e-mail [email protected]) or via a
BlackBox Value Added Reseller.
Copyright
© IP Bank B.V. 2004-2011. BlackBox is a registered trademark of IP Bank B.V. Subject to change
without notice. All rights reserved.
This document and/or any part of the document may only be used for training in the BlackBox
software tool and methodology. It may not be used for methodology-only training or training with
respect to any other tool or methodology.
This document and/or any part of the document must always be accompanied by these terms and
conditions. Without them, any possession and/or use of this material is illegal.
This document may not be published on a public download location; Value Added Resellers
(VARs) may provide this document in print and/or in PDF format only. Only VARs may distribute this
document and only to their leads and customers, none of whom may be a competitor of Governors
and/or IP Bank.
This document may only be provided by official VARs of the BlackBox software tool. Check the list of
VARs on the www.governors.nl website before using this document. If this document has not been
provided to you by an official VAR, please report this to us immediately by e-mail on
[email protected].
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1 Contents
1 CONTENTS ......................................................................................................................................................... 2
2 FIGURES OVERVIEW ......................................................................................................................................... 4
3 INSTALLATION GUIDE ...................................................................................................................................... 5
3.1 SYSTEM REQUIREMENTS .................................................................................................................................................................. 5
3.2 INSTALLATION................................................................................................................................................................................... 5
3.3 ACTIVATION ...................................................................................................................................................................................... 6
4 BLACKBOX METHOD ........................................................................................................................................ 8
4.1 INTRODUCTION ................................................................................................................................................................................ 8
4.2 TOP-SET INCIDENT INVESTIGATION METHOD ............................................................................................................................. 8
4.3 ROOT CAUSE ANALYSIS METHOD .................................................................................................................................................. 9
4.3.1 Immediate Causes ............................................................................................................................................................. 9
4.3.2 Missing Barriers .................................................................................................................................................................. 9
4.3.3 Underlying Causes ............................................................................................................................................................. 9
4.4 SMART RECOMMENDATIONS .....................................................................................................................................................10
5 STARTING ........................................................................................................................................................ 11
5.1 START INVESTIGATION ...................................................................................................................................................................11
5.1.1 New .......................................................................................................................................................................................11
5.1.2 Open .....................................................................................................................................................................................12
5.1.3 Save .......................................................................................................................................................................................12
5.1.4 Help .......................................................................................................................................................................................12
5.2 OPTIONS .........................................................................................................................................................................................12
5.2.1 Language ............................................................................................................................................................................12
5.2.2 BRF’s .....................................................................................................................................................................................13
6 REPORT TITLING ............................................................................................................................................. 14
6.1 REPORT TITLE..................................................................................................................................................................................14
6.2 DATE OF REPORT ...........................................................................................................................................................................14
6.3 AUTHOR(S) .....................................................................................................................................................................................14
7 INVESTIGATION BASIC INFORMATION ...................................................................................................... 15
7.1 DATE OF INCIDENT.........................................................................................................................................................................15
7.2 TIME OF INCIDENT .........................................................................................................................................................................15
7.3 LOCATION OF INCIDENT ................................................................................................................................................................15
7.4 WHAT HAPPENED? – SHORT DESCRIPTION.................................................................................................................................15
7.5 CONSEQUENCES OF INCIDENT......................................................................................................................................................15
7.6 POTENTIAL CONSEQUENCES OF INCIDENT..................................................................................................................................15
7.7 INJURY CATEGORIES.......................................................................................................................................................................15
7.8 INCIDENT DESCRIPTION.................................................................................................................................................................16
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7.9 WHAT WAS DIFFERENT OR HAD CHANGED? ...............................................................................................................................16
7.10 PEOPLE INVOLVED..........................................................................................................................................................................16
7.11 SEQUENCE OF EVENTS LEADING TO THE INCIDENT ....................................................................................................................16
7.12 SIMILAR EVENTS .............................................................................................................................................................................16
8 INVESTIGATION DIAGRAM ........................................................................................................................... 17
8.1 IMMEDIATE CAUSES........................................................................................................................................................................17
8.2 MISSING BARRIER ..........................................................................................................................................................................18
8.3 UNDERLYING CAUSE ......................................................................................................................................................................18
8.4 GENERIC CAUSES ...........................................................................................................................................................................18
9 ENTER REMEDIAL ACTIONS .......................................................................................................................... 19
9.1 SMART ACTIONS..........................................................................................................................................................................19
10 CONCLUSION ............................................................................................................................................... 21
10.1 REPORT OPTIONS ..........................................................................................................................................................................21
11 WORD REPORT ............................................................................................................................................ 22
11.1 CONTENTS ......................................................................................................................................................................................22
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2
2 Figures Overview
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3
3 Installation Guide
To be able to run BlackBox on your computer, please make sure the following requirements are met:
Supported Operating Systems: Windows 2000 Service Pack 3; Windows 98; Windows 98 Second
Edition; Windows ME; Windows Server 2003; Windows XP Service Pack 2; Windows Vista; Windows 7
Required Software: Microsoft .NET framework version 2.0
Disk Space Requirements: 30 MB (x86)
Important: Make sure you have the latest service pack and critical updates for the version of Windows that
you are running.
3.2 Installation
After purchasing a BlackBox license or after a trial request you will receive a download link or a memory stick
with the software. Double-click on the download link or the application on your memory stick to start the
download. When the download is complete is the application will be opened in the designated folder. Then
double click BlackBox program icon in the folder you installed it to begin. When provided with a zip. file first
unzip the file to the location you want.
After double clicking the BlackBox icon you will be prompted with Figure 1 below. Click on Run to start
the software.
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3.3 Activation
When you start the software for the first time, you will be prompted with the activation screen in Figure 2.
You can either run the software in trial mode or fill in an activation key or trial key. When you choose to run
the software in trial mode it will run for 30 days from the moment you start it the first time. After 30 days you
will need to enter an activation key to be able to run the software again.
When you have received a trial key you can fill it in the field next to ‘Activation or Trial Key’. This filed will
turn green when the code is accepted (Figure 3) .The key always consists of 8 x 2 digits, e.g. 1A2B3C4D
5E6F7G8H. It is also possible that you received an activation.dat file. In this case you don’t have to open the
file you just need to put it in the folder next to your BlackBox application (.exe file). To receive such a trial key
you can contact [email protected].
When you want to permanently activate your software you need to send us your host id (after purchasing
a license). It is displayed in the field next to ‘Current Host ID’. You can either copy and paste this code into an
email or use the ‘copy to clipboard’ button next to the host ID field. The Host ID always consists of 8 x 4 digits,
e.g. 1A2B3C4D 5E6F7G8H 9I1J2K3L 4M5N6O7P8Q. You can email this Host ID to [email protected]
or [email protected]. When you are known as a valid BlackBox-user you will receive an activation code
that can be filled in the ‘Activation or Trial Key’ field. This field will turn green when the Key is correct (Figure 3)
and you can click the ‘OK’ button.
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Figure 3 Activation Window 2
After clicking OK you will be prompted with the End-User License Agreement. This will only appear the first
time you use BlackBox. You need to accept the terms in the License Agreement to be able to run the software.
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4
4 BlackBox Method
4.1 Introduction
BlackBox is a software tool that guides you through all phases of incident analysis. The tool is used for
reporting smaller, low risks incidents or near misses and to analyze the underlying causes. The program
consists of a fixed workflow which leads you through all these steps to make complete incident report. It is
designed in a way that makes sure all fields are filled in to get standardized reports that contain the same
sections. Great care is put into making the tool easy to use.
BlackBox is based on the TOP-SET® incident investigation and analysis methodology. This method threats the
incident as a system that the organization has lost control over. Something needs to be different or changed
from the situation before to get the system out of balance. The dynamics of a system can be expressed in
different components. TOP-SET has identified six elements to investigate what has caused the incident:
Technology, Organization, People, Similar Events, and Environment that are displayed against Time (the
acronym of the word TOP-SET). The cause of the incident can be found in at least one of the five elements but
most likely in an interaction of more than one element. The Time element can be a check on the causality of
the facts found in the other five elements. In BlackBox the Time element is used in the ‘Sequence of Events’
step in which Events and their time before incident can be identified. The elements Technology, People,
Organization and Environment are used in the Incident Analysis. At least one of these elements should be
worked out in order to find the underlying causes. The element ‘People’ is in red in Figure because this
element always plays a role in every incident.
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4.3 Root Cause Analysis method
The Root Cause Analysis method that is used in the TOP-SET method is simplified for the use in BlackBox. This
gives more guidance and makes it easier to make quick but accurate analyses. In the Root Cause Analysis
method in BlackBox you are guided through three items per chosen element: Immediate Causes, Missing
Barriers and Underlying Causes.
Safety valve
Task Risk Analysis
Exclusion zone
Insufficient Procedures
Too high workload
Poor supervision Figure 6 Root Cause diagram
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4.4 SMART recommendations
In the TOP-SET method the recommendations that are made should follow the SMART principle in order to
make sure that these recommendations are useful and feasible. When following the five SMART principles you
make your recommendation as good as possible:
S Specific
Be exact in what you recommend, avoid fuzzy or vague descriptions. Don’t leave anything up to imagination;
be clear on what is expected.
M Measurable
Make sure it is clear to understand when the recommendation is successfully implemented. There should be
no doubt about the moment the recommendation has been achieved. Also assign a person who will be
responsible for the recommendation.
A Achievable
Be sure that a recommendation can be accomplished in a doable manner. Think about resources will be
necessary.
R Realistic
Think about whether the recommendation can be executed physically but also if it will be cost effective.
Consider if the costs balances out the efforts that are necessary.
T Timely
Indicate an outside date before when the recommendation should be finished. Don’t be without liability.
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5 Starting
When starting the application the start screen in figure 1 will be visible.
5.1.1 New
To start a new investigation you can click the button in the red box called ‘Start new Investigation’ (Figure 5).
An empty BlackBox file (extension .bbi) will start in the first section: Report Titling.
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5.1.2 Open
To open a saved investigation click the button ‘Load Investigation’ (Figure 5) to open an earlier saved BlackBox
file from your computer. These are all the files that end with .bbi and can be recognized with the BlackBox icon
(Figure 7) before the file name. You can also choose a file under ‘Recent Investigations’ (Figure 8) to open a
file you recently worked in. Just click on the investigation titles to open them.
5.1.3 Save
You can save you file in every step of the program. When you click the ‘Save’ button at the bottom of each
page you will get a new window to choose the location and title of your BlackBox file. When this is already
done a click on the ‘Save’ button will automatically update your file. At every page of the BlackBox tool there is
a Save button. This means that you can save your investigation at any moment and in any step making sure all
the saved file is always up to date.
5.1.4 Help
On the left bottom side of the screen you will find a ‘Help’ button. This button will activate the help box on the
left side of the screen. This blue box contains extra information about each step of the program. It will give
you explanations, examples and information about how to add, edit or remove text in the text fields. If you
don’t want to use the help box you can click on the ‘Help’ button again to let it hide from the screen.
5.2 Options
In the Start screen you will also find an ‘Options’ button. When clicking this button a window opens (Error!
Reference source not found.) where you can change the language setting and select the option to use Basic
Risk Factors (BRF’s) or not.
5.2.1 Language
The language is automatically set on ‘Default’. This means that BlackBox will run in the language that is
selected on your computer itself. If you want to change this language setting open the drop down menu.
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When you changed the language and clicked ‘OK’ the software will ask you to restart to implement the
language change. If you click ‘Yes’ the software will automatically restart. Language options are: English,
German, Dutch and Danish. More languages are expected and can be ordered with Governors.
5.2.2 BRF’s
Underneath the language option you will find an option for use of BRF’s (Basic Risk Factors). This is a
categorization used to differentiate between causes in the Root Cause analysis diagram. This can be useful to
emphasize what factors played a role during the incident and to be able to compare different analyses. There
are eleven Basic Risk Factor categories:
DE - Design
HW - Hardware
MM - Maintenance Management
HK - Housekeeping
PR - Procedures
TR - Training
CO - Communication
EEC - Error Enforcing Conditions
IG - Incompatible Goals
OR - Organization
DF - Defences
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6 Report Titling
6.3 Author(s)
To add an author you can click on the ‘Add’ button. A new row will appear where you can write the name, job
title and company. Write your name and anyone else’s name who works on this file with you. This will appear
at the beginning of the final report. Use the ‘Remove’ button to delete a row while selecting it. Double click on
the items to edit them after adding.
Please note that you can only click ‘Next’ when all the fields are filled in.
Move between the boxes by pressing the cursor keys or by clicking with the mouse. Pressing ENTER will let you edit
the text, press ENTER again to accept your changes. You may also cancel your edit with ESC.
Please note that you can only click ‘Next’ when all the fields are filled in.
Move between the boxes by pressing the cursor keys or by clicking with the mouse. Pressing ENTER will let you edit
the text, press ENTER again to accept your changes. You may also cancel your edit with ESC.
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7.8 Incident Description
This is a free text field which gives you the opportunity to describe the incident in detail. The reader of your
report will want to know some of the detail of what happened. Enter a paragraph that describes the incident.
Be aware that this is different from Step 7, which required a single line description to help you define what you
are investigating. You can write as much text as you want here.
Please note that you can only click ‘Next’ when all the fields are filled in.
Move between the boxes by pressing the cursor keys or by clicking with the mouse. Pressing ENTER will let you edit
the text, press ENTER again to accept your changes. You may also cancel your edit with ESC.
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8 Investigation Diagram
In the investigation diagram you will analyze the four remaining elements of the TOP-SET method. You need
to choose which elements you want to analyze, but at least one has to be filled in to be able to go to the next
step. Start by double clicking on one of the top immediate causes. Depending on the item that is selected in
the diagram you will find a description of what is expected from you in the help text on the left side of the
screen. The causes in the diagram will contain a specific description of the user and a linked generic cause. The
generic causes (see Figure 13) can be used to compare the causes of different incidents with because they are
all picked from the same list. In the report you will find an analysis diagram of the specific causes and one on
the bases of the generic causes.
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Figure 14 Add Images
Move between the boxes by pressing the cursor keys or by clicking with the mouse. Pressing ENTER will let you edit
the text, press ENTER again to accept your changes. You may also cancel your edit with ESC.
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9 Enter Remedial Actions
After completing the Analysis diagram you get an overview of all your Causes and Missing Barriers in the
Remedial Actions section. For each Cause and Missing Barrier you can now enter one or more actions.
information about the SMART principle go to paragraph 4.4 SMART Recommendations. Answer all the
questions with lower case sentences. All your five answers together will be formed into an action in the field at
the bottom of the window automatically. You can edit this text to change the description of the action the way
you want. After you click ‘OK’ your action will be added to the list of actions and the icon in front of the Cause
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or Missing Barrier will change (See Figure 17). Additional actions can be entered by selecting ADD button. To
remove actions select the DELETE button. When you want to edit an existing action you can click on the
button again. All the actions will be put in the report with the items they are linked to. You have to
at least add one action to be able to go to the next section.
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10 Conclusion
After the actions are defined you are ready to generate the report. In this last step of the tool you get several
options (See Error! Reference source not found.). The first option is to do a spellcheck on your BlackBox file.
This spellcheck will go through all the fields you filled in to check the spelling. You can change the language in
the drop down menu. Select the ‘Remember language’ box to save this language and use it the next times. In
the ‘Investigation’ section you can now Save or Start a new Investigation. This only applies to the BlackBox file,
not the report. The last option is to generate the report. When you generate the report it will open in
Microsoft Word after you save it. You can also edit the settings for the report by clicking on the ‘Report
Options’ link.
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11 Word Report
When clicking the ‘Report’ button, ‘Save as’ window will open to save your incident investigation report. After
saving, Microsoft Word will open automatically so you can view your report. In this report all the sections that
you selected in the ‘Report Options’ (See Figure 19) will appear. All the text in the Word Report will are
editable. Don’t forget to save your file once in a while. The report is automatically opened in the TOP-SET
format. You can change the look of your report by changing styles, font types, header colors etc. and by
adding your company logo. Governors can also provide you with a Word template following your company
standards. Please contact [email protected] for this.
Governors can also provide you with example BlackBox files and report examples.
11.1 Contents
The contents overview in the Word report is automatically updated. When you change, remove or relocate
chapters, the content overview will remain up to date. You will have to update it by right clicking the table and
selecting ‘Update fields’ > ‘Update entire table’ (See Figure 20 .
Please note that changing your report will not change the information in the BlackBox file. If you want to make
extensive changes it can be better to change the fields in BlackBox itself and then regenerating the Word report.
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