Root Cause Analysis - Investigating Incidents

A Powerful Tool for Improving Performance

Duration

• We can offer this course as a 1 day course with an optional 2nd day of practical coaching for candidates undertaking their own investigations a month or two later. We find that this is very beneficial in embedding the learning and the application of the tools and techniques in the workplace.

• We also have a more in-depth 2 day version of the course

Course Outline ‍

• 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, creating time to undertake investigations
• Investigating an incident
• 5 Whys
• Dealing with people
• Mapping and displaying an incident

• Mental Models and theories that support good RCAs, including
• Levels of Root Cause
• Human Failure Modes

• Identifying and justifying good countermeasures to prevent re-occurrences

• RCA Management Systems
• Moving from being reactive to being pro-active

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Training 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.

Why Root Cause Analysis?

Things do go wrong – breakdowns, near misses, accidents, incidents, management system failings, process safety incidents.

Unless these events are investigated and understood history will repeat itself. However, by using good Root Cause Analysis tools and techniques these events can be turned into valuable learning exercises that will reveal the underlying issues that caused the events, leading to actions to correct the cause.

Indeed, if RCAs are done as a matter of routine in response to incidents, significant improvements in performance are to be expected.

Many RCAs fail to get to the true root cause, often identifying “human error” but unable to go further.

This course will cover more than the tools for performing RCAs; it includes models and theories that will allow an investigation to go beyond human error into the deeper underlying, latent or systemic root causes, and so identify more powerful and beneficial corrective actions that will address the both the problem at hand and potential future incidents.

This moves RCAs from being a reactive investigation response, to a pro-active improvement methodology.