Day 1 – morning session
Introduction – the Nature of Mishaps and their Investigation
Accident Capture
- Aligning failure investigations with plant risk matrix
- Incident Ranking – Accident investigation vis-à-vis Risk analysis
- Personal Accidents vs Process or System Accidents
Day 1 – afternoon session
Organizing and Managing Accident and Failure Investigations
Day 2 – morning session
Problem Framing
- Problem Identification – Problem Statement
- Problem Definition – Collect Facts to Determine “What” Happened
- Human Contribution to the Failure
- Investigator/Decision-maker Biases (and how to mitigate them)
- Accountability vs Blame
Day 2 – afternoon session
Root Cause Analysis
- he Fundamental Premise and Limitation of “Root”
- Common Problems with Traditional RCA Programs
- Failure Modes vs Failure Roots
- Levels of Roots – what is a root cause, exactly?
- Accident and Failure Models
- Core Analytical Methods
Day 3 – morning session
Root Cause Analysis (cont.)
- Probable Cause Analysis – Sources of Failures, Accidents, and Incidents
- Cause Verification and Data Validation: Analysis of physical evidence to determine “how” it happened; analyze events & causal factor relationships to determine “why” it happened.
Day 3 – afternoon session
Solution Development
- When to STOP investigating
- Solution Criteria Selection – Musts / Wants
- Alternate/conceptual solutions
Elements of an Effective Investigation Report