Incident Investigation, Root Cause Analysis, and Management Oversight and Risk Tree (MORT) Certification 5-Day Workshop
Introduction to the Course: Introduction of the participants and instructor(s). Introduction to the workshop: concepts, methods, exercises, outcomes, and expectations.
Review of Key Definitions and Concepts: Introduction of key definitions and concepts. Presentation of criteria and features of conducting a state-of-the-art root cause analysis.
Conducting Investigations: Discussion of framing the investigation, developing a team charter, and allocating resources.
Conducting Investigative Interviews: Presentation on how to conduct an information gathering interview, including opening of the interview, question types and sequences, and closing the interview. Also, a discussion of handling different types of interviewees (e.g., hostile, talkative, quiet) will occur.
Events and Causal Factors (E&CF) Analysis: Presentation on guidelines, symbols, and directions for sequencing an accident on an events and causal factors chart.
Day 1 Workshop Activities:
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.
Hazard-Barrier-Target (H-B-T) Analysis: Presentation on using H-B-T to describe and analyze systems for causes.
Day 2 Workshop Activities:
Management Oversight and Risk Tree (MORT) Analysis: Discussion and illustration of the Management Oversight and Risk Tree chart. Includes a detailed discussion of the major branches of the chart and how to select the appropriate branches for use during investigations. The major branches include: Technical Information System, Emergency Response, Operational Readiness, Maintenance, Inspection, Supervision, Higher Supervision, Personnel Error (Job/Task Analysis, Procedural Fit, Selection, Training, Supervisor Observation, Motivation, and Fitness for Duty), Detailed Hazard-Barrier-Target, Management System (Policy and Implementation), Program Review, Risk Assessment/Hazard Analysis, Safety Evaluation/Modification Evaluation, Human Factors, Procedures, Support Services, and General Design.
Safety Culture and Human Performance: Examination of safety culture and human performance and their 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).
Day 3 Workshop Activities:
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.
Oral Briefings: Discussion on how to prepare, organize and deliver an effective oral briefing.