Fundamentals of Root Cause Analysis for Investigations

Objectives

This important and comprehensive course will equip the participants to:

• Learn fundamentals such as incidents, accidents and near misses
• Understand what Incident reporting is and why it is crucial
• Comprehend good Incident Reporting formats
• Categorize HSE incidents and assess risk categories
• Calculate Incident Frequency and Severity Rates
• Prepare internal and external Incident Reports
• Understand types, methodology and details of investigations
• Gain knowledge of criteria to decide types of investigation
• Understand the composition of investigation teams and responsibilities of members
• Comprehend the guidelines, skills and precautions for the execution of the investigation
• Learn and use Root Cause Analysis (RCA) to arrive at root and generic causes of incidents
• Basic knowledge of the investigation and RCA software tools
• Use the causes to develop Corrective and Preventive Action Plans (CAP & PAP)
• Check the effectiveness of the implementation of CAPs and PAPs
• Understand and practice skills to draft and generate Investigation Report
• Comprehend the importance of incident Close-out
• Cascade lessons learnt from the Incident and the RCA Report

Understand and address Insurance, Legal and Statutory Implications

Outline

MODULE 1: FUNDAMENTAL CONCEPTS

• Incidents, Accidents and Near Misses
• Occupational Injury and Illness
• Incident Pyramid
• On-work and off-work incidents
• Observer, Local Area Supervisor, Witness
• Company HSE professional
• Company medical practitioner
• How small incidents turn into major incidents?
• Some major incidents in the industry
• Difference between Incident reporting and Incident Investigation report
• Other miscellaneous common refreshing discussions and Q&A to kick off

MODULE 2: INCIDENT REPORTING

• What is Incident reporting? (i.e., notification of occurrence of an incident)
• Incident Reporting procedure (informal and formal)
• Incident Reporting formats
• Categorization of HSE incidents and assessment of risk categories
• Reportable and Recordable Occupational Injury/ Illness
• Fatality (FAT), Permanent Total Disability (PTD), Permanent Partial Disability (PPD), Lost Time Injury/Illness (LTI) Lost Time Incident (LTI)/ Lost Workday Case (LWC)/Lost Time Case (LTC)
• Medical Treatment Case (MTC) and Restricted Work Case (RWC)
• Incident Frequency and Severity Rates
• Preparation of Incident Statistics. Presentation in the Management Information System (MIS)
• Internal and External Incident Reports (notifications)

MODULE 3: CONCEPTS OF INCIDENT INVESTIGATION

• Types of Investigations (Mini, Formal)
• Criteria to decide types of investigation
• Composition of investigation teams
• Ethics, code of conduct, qualities and responsibilities of investigation members
• Preparation for investigation
• Investigation tools (manual, software-based) and methodologies (RCA, fault tree, failure analysis etc)
• Investigation Plan

MODULE 4: EXECUTION OF INVESTIGATION (DATA COLLECTION)

• Briefing by Investigation team leader on scope, limitations and logistics
• Meeting with the affected area supervisor and stakeholders where incident took place
• Site Evidence Collection (photographs, documents etc)
• Witness Interviews
• Consolidation of evidence and statements
• Site discussion/feedback with the affected parties on conclusion of data collection

MODULE 5: EXECUTION OF ROOT CAUSE ANALYSIS (RCA) 

• Preparation of the snap-chart /storyline of the whole incident chronologically
• Use of the data collected to brainstorm within team using RCA methodology
• Identification of those items which require further confirmations/data collection from site
• Review of documents, evidence, interview statements etc as RCA progresses
• Roles of Procedures, Training, Quality Control, Communications, Management systems, Human engineering, Work direction
• Carrying out the RCA and saving the work daily/regularly with different file names
• Conclusion of RCA

MODULE 6: PREPARATION OF DRAFT INVESTIGATION REPORT 

• Shortlisting/finalizing the information from the site data collection and the RCA
• Importance of a comprehensive Investigation Report
• Finalization of structure of the Investigation Report
• Allocation of responsibilities among team members as to who covers which section
• Generation of Draft Investigation Report within the timeline planned
• Review and approval of Draft Investigation Report by Investigation Team Leader
• Generation of a mini draft investigation report in parallel if client management requires it

MODULE 7: CIRCULATION OF DRAFT INVESTIGATION REPORT

• Decision on whom to circulate the Draft Investigation Report within the organization
• Circulation with a request to send comments within the stipulated time
• Receipt of comments and initial screening
• Seeking clarification on comments, if any
• Emphasis on no-suppression of information by interested stakeholders
• Escalation to area management if someone is interfering to hide sensitive disclosures

MODULE 8: FINALIZATION OF INVESTIGATION REPORT

• Decision on finalization of received comments
• No compromise with integrity of investigation report
• Incorporation of comments
• Recommendation Section must focus on clarification of actions with regards to CAP & PAP
• The final report must bear names and signatures of Team leader and members
• Production of soft and hard copies of final investigation report as per agreement
• Presentation of the report to the client to highlight summary and CAP & PAP
• Answering questions during the presentation

MODULE 9: IMPLEMENTATION OF RECOMMENDATIONS OF INVESTIGATION REPORT

• Review of the report by client area supervisor and management in detail
• Cost benefit analysis for implementation of recommendations
• Development of the plan for implementation of recommendations
• Allocation of resources to implement recommended actions as per HSE risks associated for not implementing them

MODULE 10: FOLLOW UP AND CLOSE-OUT 

• Ways to verify effectiveness of implementation of recommendations
• Observations, Interviews, and reviews of subsequent HSE reports of the affected area
• Insurance, Legal and Statutory Implications
• Archive and close-out of the incidents

MODULE 11: CASE STUDIES AND EXERCISES TO DO INCIDENT INVESTIGATION USING RCA 

• Course Facilitator runs the above investigation methodology with respect to one incident case study to refresh understanding of the participants
• Course Facilitator presents a few other case studies and asks course participants to work them out with RCA and Investigation Reports
• Course Facilitator observes progress and provides support

MODULE 12: VARIATIONS TO THE ABOVE INVESTIGATION METHODOLOGY AND EXTRAS

• Small organizations
• Low risk organizations
• Any other constraints/assumptions
• Discussions on exceptions/ clarifications on special Injury/Illness cases

Question and answers

Who Should Attend ?