Introduction to Cause Analysis 2-Day Workshop

The Introduction to Cause Analysis 2-Day Workshop is intended for participants that need to learn the skills needed to evaluate events and conditions of lesser significance. It includes 16 hours of hands-on training.

DAY ONE

Introduction to the Course: Introduction of the participants and instructor(s). Introduction to the workshop: concepts, methods, exercises, outcomes, and expectations.

Model Methodology for Cause Analysis: Introduction of key definitions and concepts. Presentation of criteria and features of conducting a state-of-the-art cause analysis.

Events and Causal Factors (E&CF) Analysis: Presentation on guidelines, symbols, and directions for sequencing an accident on an events and causal factors chart.

Fault Tree Analysis: Presentation of analytic trees, including uses, principles of construction, symbols, and examples.

Equipment and Material Failures: Discussion of how to increase ability to detect typical hardware failure signs, gather and preserve evidence of hardware failure, and trace hardware failures to causal factors in the accident sequence. Discussions will take place of how to search for information inside and outside the organization about hardware failures.

Change Analysis: Discussion on the role of change in accidents and presentation of a model for identifying elements of change.

Day 1 Workshop Activities:

DAY TWO

Hazard-Barrier-Target (H-B-T) Analysis: Presentation on using H-B-T to describe and analyze systems for causes.

Human Performance: Examination of human performance and its impact on other system components, emphasis on types of and underlying reasons for personnel errors.

Why Staircase Analysis: Discussion on using the Why Staircase analytical technique to interrogate the underlying organizational and cultural drivers of the event or condition being investigated in support of determining the root and contributing cause(s).

Determining Causes: Discussion of how to integrate various types of information into the investigation report (e.g., physical evidence, expert testimony, interviews, and analytical results). Identifying facts and formulating causal statements and causes.

Corrective Actions: Discussion on developing, writing, and evaluating corrective actions. Applying criteria and analytical techniques to corrective actions.

Day 2 Workshop Activities:

Update E&CF chart, fault tree analysis and change analysis
Perform an H-B-T analysis related to the case study
Evaluate one human performance error using the Human Performance Checklist
Perform Why Staircase analysis related to the case study
Prepare for and deliver oral briefing of analysis results
Case study review

Comments, Questions, Course Evaluation and Participant Feedback Successful completion of this training gives 1.6 Continuing Education Units (CEU).

Teaching Approach

Instruction for these classes will be presented by standard lecture methods in a typical classroom setting (or using a remote live online platform if preferred by the client) and will include hands-on workshop activities. Lectures will include audio/visual media. During the course, the participants will be assigned to teams of 3-5 people. They will conduct a simulated investigation of an incident/accident appropriate for the client. Each team will complete the analytical techniques taught during the workshop. Course trainers provide continuous mentoring and evaluations of each student’s and each group’s work. Instructor comments will be provided to the class participants on an ongoing basis throughout the course. For the final examination, each team will make a final oral presentation of the results of their investigation with instructor critique and comment.

Training Materials

Training Course materials will be provided to each participant. These materials include the training course manual, case study and supporting documents. The training materials will also include Conger & Elsea’s Mishap Analysis & Prevention System (MAPS)® Software which includes digital tools to facilitate the performance and documentation of causal analysis including Events and Causal Factors, Change Analysis, Hazard-Barrier-Target Analysis, Fault Tree Analysis, Management Oversight and Risk Tree (MORT) Analysis, and Failure Modes and Effects Analysis. All training materials are proprietary and the property of Conger & Elsea.