Incident Investigation, Root Cause Analysis, and Management Oversight and Risk Tree (MORT) Certification 5-Day Workshop

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Incident Investigation, Root Cause Analysis, and Management Oversight and Risk Tree (MORT) Certification 5-Day Workshop is Conger & Elsea’s premier training course on root cause analysis. It includes 40 hours of hands-on training and results in Conger & Elsea’s root cause analysis certification. This training has been provided to more than 18,000 people all around the world. Conger & Elsea’s training and methods have become the standard for many companies in a wide variety of industries such as public utilities (including nuclear, fossil, hydroelectric, gas and oil), pharmaceutical, engineering, manufacturing, and domestic and international regulatory agencies (including the Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Nuclear Regulatory Commission, International Atomic Energy Agency, and Canadian Nuclear Safety Commission).

DAY ONE

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:
  • Review case study
  • Develop a root cause analysis charter for the case study
  • Prepare for interviews
  • Begin constructing an E&CF chart for the case study

DAY TWO

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:
  • Update E&CF chart
  • Develop a fault tree to depict one aspect of the case study
  • Perform a change analysis related to the case study
  • Perform an H-B-T analysis related to the case study
  • Conduct “face-to-face” interviews

DAY THREE

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:
  • Update E&CF chart, change analysis, H-B-T analysis, and fault tree analysis
  • Conduct “face-to-face” interviews
  • Perform a Why Staircase analysis
  • Perform MORT analysis

DAY FOUR

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.

Day 4 Workshop Activities:
  • Complete “face-to-face” interviews
  • Complete all information gathering and analyses
  • Generate lists of facts, conclusions, and recommendations

DAY FIVE

Day 5 Workshop Activities:
  • Assemble all materials including all analyses, lists of facts, conclusions, recommendations, and other work materials
  • 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 the participants 40 Professional Development Hours (PDH) for Professional Engineers in Florida, Louisiana, Maryland, New York, and North Carolina (and almost all other states) and/or 4 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 person will perform an investigative interview and be evaluated on their performance. 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.