Accident Investigation and Root Cause Analysis

WHO SHOULD ATTEND?

Supervisors in warehouse and distribution work environments, including operational staff responsible for handling of products/goods across supply chains.

OBJECTIVES:

By the end of the workshop delegates will:

• Recognise the importance of efffective incident investigation in creating a positive safety culture in the oil and gas environment
• Know the different human failure types and how they contribute to accidents
• Identify the lifecyle of an investigation and carry out an investigation following the lifecyle
• Understand what root cause analysis is and use it in their own investigations
• Understand that incident investigation and emergency planning are related and where they sit within the overall health and safety management system.

PROGRAMME DETAILS:

Introduction

• Review of basic terms – hazard, risk, incident, accident, near miss etc
• The benefits of incident investigation – why it’s so important
• Accident investigation as part of overall management systems ref OHSAS 18001,
• HSE 65 and MAPPs
• Statistical trends and models e.g. Heinrich and Bird

Human Factors, safety management and safety culture

• An overview of human performance management
• Human failure types – slips, lapses, mistakes and violations
• Failure models
• Barriers and cultures – spotting the early warning sins
• Leadership, worker Involvement and competency

Investigation Methods and descriptions

• Review of the different tools available e.g. ARCA – APOLLO Root Cause Analysis, Black bow ties, HFIT, TapRooT
• Descriptions of each and comparison between the various options
• Linking to safety technology principles such as FMEA and Fault tree analysis

Lifecycle of an Investigation Part 1 Investigation

• Reporting
• Investigation techniques and the investigation team
• Types of evidence – what and how to gather including taking witness statements

Lifecycle of an Investigation Part 2 Analysis

• Root cause analysis and recommendations
• Action planning and management
• Sharing information (learning from incidents for continuous improvement)
• Counting the Costs of incidents - reputational management and the financial implications of incidents
• Techniques for calculating the financial cost of accidents from the simple lost time accidents to major incidents

Emergency Planning

• The importance of MAPPs (major accident prevention policies) and emergency planning
• Key elements of emergency planning
• Testing the EP and ensuring the lessons from incidents feed back into MAPP and EP

Review and Close

• Review of key learning points
• Short quiz to test understanding
• Final questions and course evaluation