Incident Investigation and Root Cause Analysis
Getting past the operator to the conditions that made the error likely
Structured investigation methods including causal tree and event and causal factor charting, applied to real cases. The course also covers the just culture question of how to judge an individual's actions fairly, using the substitution test, so that investigations keep producing information rather than blame.
This course sits alongside our Process Safety Management Systems consulting work, so what is taught is what we do.
Who should attend
Course content
Every module is taught with worked examples and exercises drawn from real plant, and adapted to your own process where the course runs in house.
Investigation management
- Scene preservation, evidence types and the order in which evidence perishes
- Team composition, independence and terms of reference
- Interviewing technique and the cognitive interview
- Sequencing what happened before explaining why
Analysis methods
- Event and causal factor charting
- Causal tree and why tree analysis
- The five whys and the point at which it stops being rigorous
- Barrier analysis and change analysis
Human performance and just culture
- Error against violation, and the distinction that changes the response
- The substitution test and asking whether another person would have acted the same
- System conditions that make an error probable
- Where individual accountability genuinely applies
Findings and follow through
- Root cause, contributing cause and causal factor kept distinct
- Writing recommendations that address the cause rather than the symptom
- Recommendation hierarchy from elimination through to procedure
- Tracking to closure and verifying effectiveness
- Sharing learning so other sites act on it
What you receive
- An investigation toolkit with charting templates
- An interview guide and evidence log
- A recommendation quality checklist
- Worked case analyses
- Assessment result and attendance record
What changes afterwards
- Investigations reach system causes instead of stopping at human error
- Individuals are judged consistently, so people keep reporting
- Recommendations change conditions rather than adding another procedure
- Learning transfers to sites that did not have the incident
Standards and references
We teach Incident Investigation and Root Cause Analysis against CCPS Guidelines for Investigating Process Safety Incidents and the codes listed with it, at the edition current when you run it.
Run Incident Investigation and Root Cause Analysis for your team
We will come back with dates, the pre-reading it needs and a cost per head. Tell us who is attending, what they already do day to day and whether you want it at your site or delivered online.
Ask about dates and cost