Root Cause Analysis - Investigating Incidents

Aims & Objectives

Things do go wrong: breakdowns, near misses, accidents, incidents, management system failings and process safety incidents. Unless these events are investigated and understood, history will repeat itself.

This course covers more than just the tools for performing root cause analysis. It includes the models and theories that allow an investigation to go beyond "human error" into the deeper underlying, latent or systemic root causes, so that more powerful and beneficial corrective actions can be identified. It moves root cause analysis from a reactive investigation response to a pro-active improvement methodology.

Suitability

Anyone responsible for investigating incidents, near misses or management system failings who needs to identify true root causes and put effective countermeasures in place.

Requirements

No prior experience is required. An optional second day of practical coaching is available for candidates undertaking their own investigations.

Syllabus

Introduction to Root Cause Analysis

• The tools, the mental models, the management systems and the benefits

RCA: The Tools

• "4C": an overall approach to incidents
• Regaining stability and safety, and creating time to undertake investigations
• Investigating an incident
• The 5 Whys technique
• Dealing with people
• Mapping and displaying an incident

Mental Models & Theory

• Mental models and theories that support good root cause analysis
• Levels of root cause
• Human failure modes

Countermeasures & Management Systems

• Identifying and justifying good countermeasures to prevent recurrence
• Root cause analysis management systems
• Moving from being reactive to being pro-active

Notes

A full hardcopy set of the slides and handouts will be given to all delegates who attend the course. Examples of RCA pro-formas and documentation are supplied for use by candidates in their own investigations.

Certification

On completion of this one-day course delegates will be issued with a certificate of attendance.