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?

• Develop Expert-Level RCA Skills. Learn how to systematically uncover the root causes of incidents using proven tools like the “5× Why,” Fishbone Diagram, and Event Tree Analysis.
• Reduce Operational Risks and Costs. Apply the 7 Quality Control Tools to identify inefficiencies, eliminate waste, and enhance process reliability across your organization.
• Produce Clear, Actionable Investigation. Reports Master the art of compiling thorough incident reports with timelines, diagrams, and corrective action plans that drive real change.
• Strengthen Analytical Thinking and Objectivity. Understand the value of impartiality, structured debate, and accurate documentation when investigating non-conformances.
• Champion Continuous Improvement. Embrace quality systems like the “5-S” method, Quality Circles, and Lessons Learned frameworks to foster a culture of accountability and growth.

Outcomes

• Identify how a sequence of contributing factors typically leads to non-conformances or incidents.
• Understand the critical role of standardized procedures, validated processes, and quality tools in effective investigations.
• Value the need for objectivity, open discussion, and meticulous documentation throughout the investigative process.
• Conduct thorough root cause analyses and produce clear, actionable 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

• Mon 3 June 2024  08:30 to 16:30
  
• Mon 3 June 2024  08:30 to 16:30