Incident Investigation for Supervisors and Engineers

Objectives

• How to meet regulatory requirements for incident investigations
• How to develop and implement a structured program 
• Designed for learning from incidents
• Why and how to define misses
• How to train others to recognize and report incidents
• Includes planning for trending of data
• How to initiate and conduct an investigation 
• Establishing an effective team quickly
• Methods for collecting different types of data, including effective interviewing skills
• How and when to apply causal factor and root cause analysis for investigating process and non-process incidents 
• Includes event and condition charting (causal factor charting)
• Filling data gaps using fault tree logic
• “5-Whys” technique for finding root causes
• PII’s Root Cause Chart™ for categorizing root causes
• How to develop appropriate recommendations to address root causes at various levels to avoid future incidents
• How to structure reports
• Via actual industry examples and workshops, learn key points and practice your new skills

Outline

Workshop: Identifying near misses (near hits):

• Initiating the investigation
• Gathering data
• Basics
• Gathering data from people
• Gathering data from documentation, parts, and chemicals

Workshop: Identifying key data needs:

• Analyzing data for ALL causal factors

Workshop: Causal factor charting:

• Bridging gaps in data

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
• Use PII’s Root Cause Chart ™ to determine the multiple root causes of each 
•   causal factor

Who Should Attend ?

Engineers – process, process safety, and mechanical – Operations and Maintenance supervisors