Root Cause Analysis 3-Day Refresher 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.
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.