Root Cause Failure Analysis

To equip participants with management and cognitive tools to promote a self-learning organization relating to failure investigations within an oil & gas context; to enable the participants to apply those tools on actual facility incidents, current and future.

Day 1 – morning session
Introduction – the Nature of Mishaps and their Investigation
Accident Capture

• Aligning failure investigations with plant risk matrix
• Incident Ranking – Accident investigation vis-à-vis Risk analysis
• Personal Accidents vs Process or System Accidents

Day 1 – afternoon session
Organizing and Managing Accident and Failure Investigations

Day 2 – morning session
Problem Framing

• Problem Identification – Problem Statement
• Problem Definition – Collect Facts to Determine “What” Happened
• Human Contribution to the Failure
• Investigator/Decision-maker Biases (and how to mitigate them)
• Accountability vs Blame

Day 2 – afternoon session
Root Cause Analysis

• he Fundamental Premise and Limitation of “Root”
• Common Problems with Traditional RCA Programs
• Failure Modes vs Failure Roots
• Levels of Roots – what is a root cause, exactly?
• Accident and Failure Models
• Core Analytical Methods

Day 3 – morning session
Root Cause Analysis (cont.)

• Probable Cause Analysis – Sources of Failures, Accidents, and Incidents
• Cause Verification and Data Validation: Analysis of physical evidence to determine “how” it happened; analyze events & causal factor relationships to determine “why” it happened.

Day 3 – afternoon session
Solution Development

• When to STOP investigating
• Solution Criteria Selection – Musts / Wants
• Alternate/conceptual solutions

Elements of an Effective Investigation Report