Human Error; Human Error Prevention; Human Error Reduction; Error; Human Performance; Human Performance Improvement; Root Cause Analysis; Corrective Action; Process Improvement

INCIDENT / FAILURE INVESTIGATION, ROOT CAUSE ANALYSIS & CORRECTIVE ACTION – 2 DAYS
Ben Marguglio

Learning Outcomes

Upon completion of this seminar, one will understand:

• Problem / condition reporting, root cause analysis, and corrective action terminology;
• How to perform or facilitate root cause analysis using any of the techniques listed in the Outline, below;
• How to design and implement a problem / condition reporting, root cause analysis, and corrective action system;
• How to manage or assess such a system.

Outline

• System participant responsibilities
• System participant responsibilities
• System capabilities
• Condition data collection criteria
• Standard data tables / Data to be collected, and why
• Condition definition
• Fact versus conclusion
• Extent of Problem / Condition Analysis
• Operating experience
• Risk-based initial screening of condition reports
• Risk, urgency and significance
• Root, contributing and direct causes
• Criteria for action
• Administration of root cause analysis
–– Root cause analysis team / individual qualifications
–– Root cause analysis charter
–– Root cause analysis plan
• Data collection
• Interviewing
—— Preparations
—— At the scene
—— Interviewing template
• Root cause analysis techniques
–– The 5 WHYs
–– Change Analysis
–– Failure Mode & Effects Analysis with examples
–– Modified Hazard-Barrier-Effects Analysis / Process Design & Implementation Analysis with a case study using a template
–– Time-Line Analysis with a case study using a template
–– Cause & Effects Analysis / Fishbone Diagrams with examples
–– Probabilistic Risk / Safety Analysis, with Event & Fault Trees with examples
–– Process Flow Diagrams with examples
–– Value Stream Diagrams with an example
–– Other
• Hardware failure modes
• Hardware failure causes
• Human performance root causes
• Extent of Cause Analysis
• The eight types of corrective action
• Elements of a corrective action commitment
• Corrective action verification techniques
• Leading and lagging performance indicators
• Performance and status indicator reports

Handouts

• Copy of approximately 150 PowerPoint slides used in the seminar
• Copy of approximately 10 case studies and exercises used in the seminar
• Copy of templates used for Modified Hazard-Barrier-Effects Analysis / Process Design & Implementation Analysis and Time-Line Analysis
• Certificate of Completion showing 15 education hours, with 1.5 Continuing Education Units that may be used toward university course credits or professional re-certifications, signed by Ben Marguglio

 

Human Error; Human Error Prevention; Human Error Reduction; Error; Human Performance; Human Performance Improvement; Root Cause Analysis; Corrective Action; Process Improvement