This course teaches how to lead investigations and root cause analysis using various techniques such as Causal Factor Charting, Fault Tree Analyses, and Root Cause Charts.

Upon successful completion of this course, the delegates will be able to:

·         Meet regulatory requirements for incident investigations

·         Develop and implement a structured program designed for learning from incidents, why and how to define misses

·         Train others to recognize and report incidents including planning for trending of data, pareto charts, weibull analysis for failures and other graphical and predictive techniques

·         Initiate and conduct an investigation

·         Establishing an effective team quickly

·         Apply methods for collecting different types of data, including effective interviewing
skills

·         Apply causal factor and root cause analysis for investigating process and non-process incidents includes event and condition charting (causal factor charting), filling data gap using fault tree logic, “5-Whys” technique for finding root causes and PII’s Root Cause Chart™ for categorizing root causes

·         Develop appropriate recommendations to address root causes at various levels to avoid future incidents

·         How to structure reports

·         Learn key points and practice new skills via actual industry examples and workshops

This course is intended for engineers, process, process safety, and mechanical - operations and maintenance supervisors.

Day 1:

·         Basics of incidents and investigations

·         Workshop: Identifying near misses (near hits)

·         Initiating the investigation

o   Gathering data

o   Basics

o   Gathering data from people

o   Gathering data from documentation, parts, and chemicals

o   Assigning personnel and tasks

·         Workshop: Identifying key data needs

·         Analyzing data for ALL causal factors

Day 2:

·         Workshop: Causal factor charting techniques

o   Pareto Analysis

o   Fishbone Analysis

o   Weibull Analysis

o   Bowtie Analysis

o   Examples of each type of analysis

o   Fault Tree Analysis

o   Fuzzy Fault Trees

o   Markov Chains & Bayesian Analysis

o   Failure Modes Effects Analysis

o   Reporting Feedback

·         The investigator’s tool kit

o   Cameras

o   Analytical Tools

o   Laboratory – type and kinds

o   Model Shop & Machine Shop

·         Practical Techniques

·         Bridging gaps in data

·         Workshop: Using the tools & charts to find out most probable causes

Day 3:

·         Refining your analysis to get to the real root causes

·         Determining ALL other contributing causes of each causal factor

·         Workshop: Identifying root causes using the “Root Cause Chart” techniques & others for causal identifications

·         Developing conclusions and recommendations

·         Consensus and disagreements

Day 4:

·         Team Management

·         How to write the report- what’s in it

·         Workshop: Conclusions and recommendations based on facts

·         The minority report as alternative theories.  What, where, and when

·         Overview of results trending

Day 5:

·         Preparing for the Case Study

·         Case Study: Using all rules and methods taught in class to investigate actual incident in real-time setting

·         Practical Exercises using real data

·         Small teams will:

o   Determine data needs

o   Gather data (interview role-players, get data from computer control systems, etc.)

o   Use causal factor charting and fault trees to analyze data and determine ALL causal factors

o   Use PII’s Root Cause Chart ™ to determine the multiple root causes of each  causal factor

o   Draft effective recommendations and make presentation to class

A variety of methodologies will be used during the course that includes:

·         (30%) Based on Case Studies

·         (30%) Techniques 

·         (30%) Role Play

·         (10%) Concepts

·         Pre-test and Post-test

·         Variety of Learning Methods

·         Lectures

·         Case Studies and Self Questionaires

·         Group Work

·         Discussion

·         Presentation

To be advised as per the course location. This rate includes participant’s manual, Hand-outs, buffet lunch, coffee/tea on arrival, morning & afternoon of each day.

Daily Course Timings:

    08:00 - 08:20       Morning Coffee / Tea

    08:20 - 10:00       First Session

    10:00 - 10:20       Recess (Coffee/Tea/Snacks)

    10:20 - 12:20       Second Session

    12:20 - 13:30       Recess (Prayer Break & Lunch)

    13:30 - 15:00       Last Session