Root Cause Analysis Training

This course will provide participants with the necessary tools to perform high quality apparent and root cause evaluations. It includes discussions on: investigative interviewing, hardware failure recognition and analysis, and the use of state-of-the-art root cause analysis methods including events and causal factors analysis, analytic logic trees, change analysis, and hazard-barrier-target analysis.  A rigging accident case study will be used throughout the workshop to provide the participants an opportunity to utilize the tools presented during the course.

 Participants will work in teams to conduct the simulated investigation. Each team will perform an investigative interview and be evaluated on their performance.  They will receive mentoring and feedback throughout each day as they complete analytical techniques taught.  The results of the workshop will be summarized on Day 2 through oral presentations by each team.

All training materials including a course manual, case study and supporting documents will be provided.

DAY ONE

Introduction to the Course:  Introduction of the participants and instructor(s). Introduction to the workshop:  concepts, methods, exercises, outcomes, and expectations.

Model Methodology for Root Cause Analysis: Review of key definitions and concepts. Criteria, features, and illustrations of conducting a state-of-the-art root cause analysis.

Conducting Investigative Interviews:  How to conduct an information gathering interview, including the 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).

Events and Causal Factors (E&CF) Analysis: Guidelines, symbols and directions for sequencing an accident on events and causal factors chart.

Fault Tree Analysis:  Description of fault tree analysis, including: uses, principles of construction, parts, symbols, and examples.

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.
• Begin constructing a fault tree to depict one aspect of the case study.

DAY TWO

 Hardware Failure Recognition & Analysis:  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.  Discussion of how to search for information inside and outside the organization about hardware failures.

Change Analysis:  Exploration of the role of change in accidents and a model for identifying elements of change.

Hazard-Barrier-Target (H-B-T) Analysis:  Using H-B-T to describe, design and analyze systems for root causes.

Determining Causes: Discussion on how to utilize facts and analytical results to develop causal statements.

Workshop Activities:

• Update E&CF chart.
• Update fault tree.
• 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.
• Prepare for and deliver oral briefing of analysis results.

FEES: Open to MCA Member and IBF Contributing Companies - $500/person. *Invoices will be sent out following the course completion. 

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INSTRUCTOR: Richard  A. Rasmussen

Mr. Rasmussen holds more than 35 years of experience as a safety professional and is Conger & Elsea’s Director of Consulting Services.  He is certified as a Root Cause Analyst and as a Management Oversight and Risk Tree (MORT) Root Cause Analysis Trainer with specialization in analytic techniques for incident investigation and accident prevention.  Prior to joining Conger & Elsea, Mr. Rasmussen had 23 years of dedicated service with the U.S. Nuclear Regulatory Commission (NRC) that included assignments as a Resident and Senior Resident Inspector, Senior Reactor Analyst (SRA), and several leadership positions including his last assignment as Chief, Electrical Vendor Inspection Branch.   He holds a Bachelor of Science in Mechanical Engineering from California State University – Fresno.