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Root Cause Analysis

  • Investigation committee leaders in charge of analyzing HSE or Reliability incidents.
  • Methodology to investigate incidents with a team.
Learning Objectives
  • Effectively define a problem.
  • Create and manage the investigation committee.
  • Find root causes related to Management Systems.
  • Identify the best solutions.
  • Communicate and convince Management.
Ways and means
  • Practical exercises at each step of the method, based on actual refining/chemical situations:
  • role playing on the second day, based on actual and complex cases
  • demonstration of existing software supporting the method
  • upon request, specific site culture, procedures, software packages and actual incidents can be used.

Principle and key steps 1 day
  • Immediate action following the incident: initial investigation, physical and visual evidence gathering, interview of witnesses and documentation of their reactions, pictures, field visit.
  • Team selection: facilitator and team members selection, validation by Management.
  • Problem definition: difference between events and problems, circumstances, actual and potential impacts, prioritization.
  • Understanding causes: various methods to start a cause and effect chart. Difference between chronological and logical relationships, key role of the barriers, identification of missing and inadequate barriers.
  • Active failure: understanding of human error and of its various possible causes, relationship with the barriers.
  • Conditions: relationship between active failures and conditions. Understanding that conditions belong to the cause and effect relationship. Importance to consider conditions as causes. Cause categories by type: equipment, hardware, organization, procedures, people, roles and responsibilities.
  • Management Systems: definition, importance for the company to take them into account. Main Management Systems at the source of incidents, interest of predefined Management System categories.
  • Recommendations: how to move from the cause and effect chart to recommendations. Exploring possible solutions. Techniques to find creative options. Validity check (SMART recommendations). Prioritization of valid recommendations.
  • Action plan: Management involvement, reasons and consequences. Presentation techniques. Final validation.
  • Reporting: base elements of a clear and complete report.
Practical investigations 1 day
  • Application n°1: application of the whole method on a simple case, by teams of 3, everybody having the same information, and the Trainer providing additional necessary information, as requested. Feedback from one team, group discussion.

  • Application n°2: role play by teams of 4 to 5, each participant knowing specific information. Nominated facilitator having no information available. Feedback from one team, group discussion. Closing comments from the Trainer.