Introduction:
Several industries have adopted excellent accident investigation and analysis techniques. It is a basic function of the HSE Management System to locate and define the operational errors that allow accidents to occur. Competence in the application of modern accident/incident investigation tools will assist organizations to learn and to prevent the recurrence of accidents and to evaluate the extent and location of management defects (root-causes), which contributed to the accident event. A good analytical accident investigation is invaluable to achieve continuous improvement in an organization’s HSE performance.
Course Objectives:
Participants attending the programmer will:
- Define the accident / incident event
- Understand modern accident causation theories
- Define all accident investigation and analysis stages
- Carry out Initial actions in response to accident and incidents
- Gather evidence and data relevant to the accident investigation
- Interview witnesses
- Analyze the role of human factors involvement in accident investigation
- Compile accident reports and remedial action plans
- Gain familiarity with modern accident analytical techniques for root-cause analysis
- The use of accident investigations as a management audit tool
- To locate and define active human error, preconditions and root causes
- Report writing and compilation
Who Should Attend?
- All Supervisors and line management responsible for initial actions following an incident on site
- All HSE personnel
- Technical personnel who will be involved in forensic investigations
- Independent personnel with the role of analyzing incidents to identify root causes
Course Outlines:
- Course Introduction and Structure
- Accident investigation and the blame culture
- The Relationship between ‘Accidents’ and ‘Incidents’
- Human error and contribution to accidents
- Framework for Accident Investigation and Analysis
- Management systems (latent) failures and root causes for accidents
- Incident Investigation Framework
- Why and who should investigate?
- The role of the ‘Organization’ in Accident Causation and effects.
- Reason’s accident causation model
- Development of the ‘no blame’ culture
- Human error and accident causation
- Framework for accident investigation process
- Witnesses interview techniques
- Introduction to Cause Tree Analysis (CTA)
- Applications for CTA
- Incident Investigation and Analysis Techniques
- The principle stages of an Accident Investigation
- Planning the investigation
- How to counteract investigator bias and mindset
- Introduction of advanced accident investigation tools (Fault Tree Analysis)
- FTA as an accident investigation tool
- FTA as an accident analysis tool to identify root-cause
- Events and Causal Factors Analysis ‘E&CFA’
- Introduction to E&CFA
- Applications for E&CFA
- Major Case Study for application of analytical techniques (Group work)
- Case study Report back
- When to use CTA, FTA and E&CFA
- Reports Preparation, Planning and Implementing
- The role of a lead accident investigators
- Analysis of the consequences- Forensic evidence
- Modeling fire, explosion and toxic releases
- Preparation of reports, conclusions and recommendations
- The use of accident investigation as a Audit tool
- Discussion and course review