Incident Investigation

Course objective

By the end of this training participants will:

  • Enable trainees to think of incident before they occur to prevent then form occurring in first place.
  • Describe when and why to do incident investigation.
  • Introduce the main terminology used in incident investigation context.
  • Enable the attendees to connect and understand the relation between incident investigation and the other process safety and reliability activates studies like Hazop, SIL assessment, SIL verification and RAM (reliability, availability and maintainability) analysis
  • Describe ow to design an efficient incident investigation management system
  • Explain the most common investigation techniques (e.g.  ECFA, barrier analysis, use of bowties, MORT, RCFA, etc.) and when and how to use each.
  • Enable the trainees to use incident investigation techniques to produce reports, lessons learned and recommendations to better operate, maintain and support operation of and equipment of facility safety.
  • Give real examples of use of incident investigation techniques in real plants.

Methdology & Participant profile:

A highly interactive combination of lectures and discussion sessions will be managed to maximize the amount and quality of information and knowledge transfer. The sessions will start by rasising the most relevant questions, and motivated everybody find the right answers.

You will also be encouraged to raise your own questions and to share in the development of the right answers using your own questions and to share in the development of the right answers using your own analysis and experiences.

Attendees include engineers and technicians working in operation and maintenance equipment (mechanical, electrical, instrumentation, valves, etc. ) as well as process safety engineers, functional safety engineers and incident investigators.

Course Duration            

5 days (For the full course)

 Optional: Exam on and additional day.

Certicate/ Certification

All training participants who participate actively receive a certificate from our office in Oslo.

To be certified (get a certification, not just a certificate), this requires a certification procedure as per NS EN BS ISO IEC 1704 which includes assessing the qualifications, interviewing asn passing an exam.

Course Outline

Module 1–Overview & Introduction

  • Why do you take incident investigation training?
  • How does and effective investigation system affect the plant safety reputation and profit?
  • Main terminology used
  • Incident causation theories

 

Module 2- Bowite analysis Methodology

  • Events and causal factors analysis
  • Barrier analysis and use of bowties
  • Tripod diagram
  • MORT (tree)
  • Root cause failure analysis
  •  Selecting the appropriate method
  • Investigation near misses
  • Discussing the role of human factors

Module 3- Special consideration in Bowtie analysis

  • Preplanning
  • Team formation and leadership
  • Blame -free stratey
  • Reporting
  • Deducing lessons learned and producing recommendations

Module 4 How to use bowties in improving safety & reliability

  • Evidence sources
  • Gathering evidence
  • Analyzing evidence
  • Organizing data with a timeline
  • Determining root causes

Module- 5 Lessons learned and reporting

  • How to develop lessons learned and effective recommendations
  • Types of recommendations
  • Report format
  • Liability and legal insights
  • Follow up and implementing recommendations (have the lessons learned been really learned? )
  • Updating failure data for use in LOPA QRA, RAM analysis and SIL assessments

Module- 6  Full Example

  • Case study (s)
  • Discussing previous incidents at your plant if any