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Incident Investigation

There is never a single cause for an accident or an incident and the source of each accident and the subsequent analysis should build a picture of events and how to avoid accidents and incidents in the future. Accident & Incidents are time consuming but essential processes for preventing further damages or losses. This course is designed to give the participants an insight in the complexity of Accidents and Incidents and the methods for prevention and reducing both Accidents and the resulting costs. It is also gives the process of Accident and Incident Investigation and analysis of physical and documentary information and the formulation of a conclusive report with positive recommendations.

Course Objectives
Managers will be able to define the principles of incident investigation by practical exercise and detail assessment.

Course Outline

  1. Incident Reporting and Documentation (2 days)
    • Basics Of Incident Investigation
    • The Need for Incident Investigation
    • Rational for Taking a Structured Approach to Incident Investigation
    • Depths of Analysis
    • Structured Analysis Process
    • Selecting Incidents to Investigate
    • The Investigation Thought Process
    • Differences Between Traditional Problem Solving and Structured RCA
    • The Typical Investigator
    • A Structured Approach to the Analysis
    • RCA Within a Business Context
    • The Elements of an Incident
    • Causal Factors and Root Causes
    • The Goal of the Incident Investigation Process
    • Levels of the Analysis: Root Cause Analysis and Apparent Cause Analysis
    • Initial Incident Reports and Corrective Action Requests
    • Reasons to Generate an IIR or CAR
    • Typical Information Contained in an IIR or CAR
    • Using the IIR or CAR in the Incident Investigation Process
    • Incident Classification
    • Summary

  2. Incident Investigation and Analysis (5-WHY-TREE) (5 days)
    • Introduction
    • Root Cause Analysis Basics
    • Local Incident Investigation Procedure Review
    • Root Cause Analysis Process
      • Incident Occurs
      • Gather Data
      • Form Team
      • Develop Sequence of Events
      • Identify Protective Systems
      • Determine Root Causes (Five Why, Why Tree)
      • Verify Causes
      • Role Play - Investigation
      • Develop Recommendations
      • Document  Investigation
      • Review & Issue Report
      • Categorize Root Causes
    • Keys to Successful Facilitation
    • Summary

  3. Incident/Accident Data Analysis (2 days)
    • Introduction
    • General Guidelines
    • Why Be Careful When Selecting Incidents for Investigation?
    • Selecting Incidents For Analysis
    • Near Misses
      • Factors to Consider When Defining Near Misses
      • Reasons Why Near Misses Should Be Investigated
      • Barriers to Getting Near Misses Reported
    • Acute Analysis Versus Chronic Analysis
    • Using Pareto Analysis for Environmental, Health, and Safety Incidents
    • Examples of Pareto Analysis
    • Weaknesses of Pareto Analysis
    • Prioritizing the RCA Efforts
    • Benefits of a Trending Program
    • Data to Collect – Defining, Determining, Deciding
    • Data Analysis
    • Interpreting Data Trends & Patterns
    • Summary

  4. Accident Prevention Program (1 day)
    • Introduction
    • Recommendations – Timing, Levels & Types
    • Eliminate the Hazards – Reduce the Risks!
    • Make the System Inherently Safer or More Reliable
    • Prevent Occurrence of the Incident
    • Management Responsibilities
    • Assessing Benefit/Cost Ratios
    • Assessing Recommendation Effectiveness
    • Summary

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