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ICTD International Centre for Training and Development

Advanced Incident Investigation

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Description

Most organizations have Incident investigation procedures. However, these procedures are often based on a blame culture and do not inspire the investigator to find and correct the weaknesses in the management system (root causes) that allowed the hazards to exist and the accident to occur.

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.

This intensive five-day course will enable you to:

  • 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 analysis techniques
  • The use of accident investigations as a management audit tool
  • To locate and define active human error, preconditions and root causes
  • Plan and implement Action Plans
  • Reactive and proactive monitoring of performance
  • Benchmarking within the Industry

Course Objectives

Upon successful completion of this course, the delegates will be able to:

  • Explain accidents and explain their relationship to incidents
  • Explain the causes of accidents using accident causation models
  • Interview witnesses
  • Carry out initial actions following an incident on site and collect factual evidence
  • Detail the methods for effective evidence gathering and preservation
  • Lead Incident Investigation Team
  • Coordinate the AI Team activities
  • Compile a corrective action report and presentation
  • Conduct root-cause analysis
  • Apply modern incident investigation and analysis techniques that includes Cause
  • Tree Analysis (CTA), Fault Tree Analysis (FTA), Events & Causal Factors Analysis (E&CFA)

Course Outline

Day 1

Framework for Incident Investigation and Analysis

  • Course Introduction and Structure
  • Accident Investigation and the Blame Culture
  • The Relationship between 'Accidents' and 'Incidents'
  • Human Error and Contribution to Incidents
  • The Link Between Reactive and Pro-active Risk Management
  • Framework for Accident Investigation and Analysis
  • Management Systems (Latent) Failures and Root Causes for Accidents

Day 2

Accident Investigations and Analysis (Cause Tree Analysis)

  • Why and Who Should Investigate?
  • The Role of the 'Organization' in Incident Causation and Effects
  • Reason's Accident Causation Model
  • Development of the 'No Blame' Culture
  • Human Error and Accident Causation
  • Witnesses Interview Techniques
  • Introduction to Cause Tree Analysis (CTA)
  • Applications for CTA

Day 3

Accident Investigation and Analysis (Fault Tree Analysis)

  • 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-Causes

Day 4

Events & Causal Factors Analysis

  • 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

Day 5

Planning and Implementing

  • The Role of Incident Investigation Team Leader
  • Analysis of the Consequences-Forensic Evidence
  • Modeling Fire, Explosion and Toxic Releases
  • Preparation of Reports, Conclusions and Recommendations
  • The Use of Accident Investigation as an Audit Tool
  • Discussion and Course Review

Course Methodology

A variety of methodologies will be used during the course that includes:

  • (30%) Based on Case Studies
  • (30%) Techniques
  • (30%) Role Play
  • (10%) Concepts
  • Pre-test and Post-test
  • Variety of Learning Methods
  • Lectures
  • Case Studies and Self Questionaires
  • Group Work
  • Discussion
  • Presentation

Who should attend

This course is intended for all staff from supervisors to senior management with roles and responsibilities for safety in the workplace. In addition, all safety professionals or risk managers need to have a full understanding of the modern tools available to be competent in accident investigations

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