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THE JMDECKER GROUP HAWAII  LLC

Incident Investigation & Root Cause Analysis

(Problem Solving & Hands-on break out sessions)

Course Duration: 4 Hours
The JMDecker Group Hawaii, LLC
Training Outline

 

Objective:


To provide descriptive guidelines and the latest investigated practices to accurately indentify root causes.  With techniques practiced during this seesion the participant will acquire the confidence to lead, conduct, and solve incidents objectively leading to reduction of future system failures and increased profitability.

 Scope:

Participants will utilize the Incident Investigation workbook designed to meet the legislative requirements for incident reporting and investigation outlined in the OSH Act and HIOSH Regulations.

Course Description:
This course teaches how to lead investigations and root cause analyses using various techniques such as Causal Factor Charting, cause mapping and Root Cause Charts. This is a “How To” course designed to teach skills.

Course Outcomes:
Upon successful completion of the course, participants will be able to recognize and mitigate incidents through a methodic process which leads to a Root Cause to include the following:


  • Basics of incidents and investigations

  • Workshop: Identifying near misses (near hits)

  • Initiating the investigation

  • Gathering data

  • Gathering data from people

  • Gathering data from documentation, parts, and interviews

  • Analyzing data for ALL causal factors

  • Workshop: Causal factor charting

  • Workshop: Using fault tree analysis to find all possible scenarios and determine the most likely one

  • Determining ALL root causes of each causal factor

  • Workshop: Identifying root causes using the “Root Cause Chart” technique

  • Developing conclusions and recommendations

  • Workshop: Conclusions and recommendations based on facts

  • Overview of results trending

  • Preparing for the Case Study


 Case Study: Using all rules and methods taught in class to investigate actual incident in real-time setting. Small teams will:

  • Determine data needs

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

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

  • Draft effective recommendations and make presentation to class