Root Cause Analysis 3-Day Refresher Workshop

The Root Cause Analysis 3-Day Refresher Workshop is intended to provide periodic refresher training to participants who have previously been trained or qualified in root cause analysis techniques. This workshop also provides participants familiar with root cause analysis techniques an in-depth understanding on the implementation of the Management Oversight and Risk Tree (MORT) analytical technique. It includes 24 hours of hands-on training.


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.
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.

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 1 Workshop Activities:


Introduction to MORT: Presentation of the Management Oversight and Risk Tree, its history, development, and applications.

Preliminary Ideas: Discussion of ideas to enhance the understanding of MORT: risk, tree structure, oversight vs. risk, conventions, time universal application, and data administration needed for source referencing the analysis.

MORT Analysis: Specific Control Factors: Discussion, application, and exercises on amelioration; H-B-T (accident); technical information; facility functional operability, maintenance; inspection; supervision; human error; and higher supervision services.

Day 2 Workshop Activities:


MORT Analysis: Management System Factors: Discussion, application, and exercises on policy, implementation of policy; risk assessment system; concepts and requirements; design and development plan; human factors review; and program review.

MORT Analysis: Safety Culture: Discussion of evaluating impacts of Safety Culture using the MORT traits and attributes.

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 3 Workshop Activities:
Comments, Questions, Course Evaluation and Participant Feedback Successful completion of this training gives 2.4 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 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, Inc.