A method for unraveling the complexity of single disaster cases: Lessons for “normal” functioning

This article develops a new method for (re)analyzing data from a single disaster case to identify the temporal chain of collections of factors that was sufficient to lead to a disaster. The method combines elements of existing process methods with Mackie's (1965) interpretation of causal complexity; the INUS concept: An Insufficient but Necessary factor from a collection of factors that is Unnecessary but Sufficient for the effect. By systematically analyzing the factors that have changed shortly before the occurrence of the disaster, the method identifies not only the (collection of) factors that are sufficient for the disaster but also—by logical transformation—the collection of reversed factors that enable and ensure “normal” functioning without similar disasters and can be acted upon by management. We provide step-by-step guidelines for the graphical representation of the complexity of the disaster and the related “normal” functioning by showing the temporal relationships between collections of factors. The method may help develop an impact in two ways: first, in eliciting the factors necessary to avoid similar disasters, and second, in allowing dialogical sensemaking with practitioners at each step of the process.