Overview

RCA is a reactive method to identify both the obvious and the underlying causes of a non-conformance or incident so that specific solutions can be implemented. A complete RCA consists of a clear definition of the problem, a thorough analysis supported by evidence, a specific corrective action plan for implementing the solutions and monitoring the effectiveness of those corrective actions.

For complex problems and costly blunders, a thoroughly documented multi-faceted incident investigation report may be required. A standardised layout, logical recording and well considered reasoning are of cardinal importance when the causes and contributing factors of incidents are to be established and presented. The method of recording will not only make the job of the investigator(s) much easier but will also enable the Review Board to issue instructions that will effectively address the root cause(s) to prevent a recurrence.

Why Should an Individual Attend?

• The delegates will have an understanding of Root-Cause Analysis and the application of the 7 Quality Control Tools to enable risk, cost and waste reduction in a company.
• The purpose of the course is to offer proven RCA, incident investigation and reporting techniques to enable course delegates to accurately establish the causal factors that led to a non-conformance or incident, to recommend immediate corrective and appropriate preventive actions, and to compile an accurate feedback report.

Outcomes

• Recognise that generally a chain of events is required to result in a non-conformance/incident.
• Appreciate the significance of appropriate procedures, approved processes and quality tools when investigating non-conformances and incidents.
• Respect the importance of impartiality, thorough debating, and diligent recording.
• Undertake effective RCAs and compile meaningful incident investigation reports.

Program Outline

Introduction

• Reasons for Root Cause Analyses and Incident Investigations
• Quality - the Golden Thread
• Investigator Attributes and Investigation Techniques
• Terminology
• Incident Barriers - the Swiss Cheese Model
• Categorisation of Findings
• Pareto Analysis
• Common Pitfalls.

Root Cause Analysis

• Tools and Methodologies
• Event and Causal Factor Diagram
  
  • Accident Investigations
• 9-Step Conventional Techniques
  
  • Change Analysis
  • Ishikawa (Fish Bone) Diagram
  • "5× Why"
  • Event (Fault) Tree Analysis
  • Conclusions (Corrective Action Plan, Prevention and Validation)
• Failure Mode, Effects and Criticality Analysis (FMECA)
• Root Cause Analysis Register
• Root Cause Analysis: Strengths vs. Limitations, and Other Methods 
• Incident Investigation
• Introduction: Counterfeit Parts
• Typical Process Map
• Report Layout
  
  • Timelines and Diagrams
  • Report Writing Considerations
  • Incident Classification
• Risk Assessment Matrix
• Legal Considerations.
• Continuous Improvement
• Man-Man and Man-Machine Interface
• 12 Principles of Error Management
• Determining Individual Culpability
• Skill-Rule-Knowledge (SRK) Framework
• Effective "Quality Tools"
  
  • Special Processes
  • Inspection Stamps
  • Quality Circles and Continual Improvement
• Quality Control Tools
  
  • Flowchart
  • Histogram
  • Scatter Diagram
  • Stratification
  • Check Sheet
  • Statistical Process Control (SPC) and Control Charts
  • The "5-S" System
• Plant Performance Trending (brief introduction)
• Random Surveillance Audits
• Quality Alert
• Reading Log
• Lessons Learned System (brief introduction).

Who Should Attend?

• Engineers
• Technicians
• Technologist
• Architects
• Project / Construction Managers
• Quantity Surveyors
• Construction Health and Safety
• Contractors / Sub Contractors
• Middle Management
• Senior Management