Element 1: Introduction to Incident Investigation

• Key Terms in Incident Investigation

• How Human and Organizational Factors Contribute to Incidents:

  • Human factors, human errors and their causes in incidents

  • The difference between intentional violations and unintentional errors

  • Types of errors and violations

• The Importance of Investigating Incidents and Near Misses and Identifying Root Causes

  • How and why identifying the root causes of incidents helps prevent future incidents and saves the company money

• Step-by-Step Guide to Investigation Process

  • Incident notification and initial response

  • Fact gathering (site and physical evidence survey, witness interviews, document / record review)

  • Analyzing the collected facts and determining the causes of the incident

  • Developing and planning corrective and preventive actions

  • Developing an incident investigation report

  • Learning lessons from incidents

• Incident Notification and Initial Response

  • Practical exercise: Developing an incident notification and creating a "flash report"

• Different Levels of Investigation (Minimal, Low, Medium, and High)

  • Creating an investigation team (role of the chairperson, selecting team members, competencies for team members)

 

Element 2: Gathering Facts

• Scene Survey and Evidence Collection

  • Collection of physical evidence

  • Document / record review

  • Effective witness interviewing skills

  • Collection of written statements

  • Using the PEACE model for interviews (Planning and Preparation, Engage and Explain, Account, Clarification and Challenge, Closure, Evaluation)

  • Practical exercise: developing interview questions for witnesses

• "Blame Practices" in Investigation and Witness Interviews

  • Why they are common and how they hinder successful investigations and interviews

• Psychological biases during interviews

  • Types, examples, and how they negatively impact interviews and investigation conclusions

  • Practical exercise: Recognizing psychological biases during interviews

 

Element 3: Analyzing Facts and Root Causes Analysis (RCA)

• Identifying the sequence of events leading to the incident (storyboarding and creating a chronological timeline)

  • Practical exercise: Creating an incident timeline and identifying critical factors

• Differentiating between Immediate, Underlying, and Root Causes

• RCA: cause-and-effect logical methods "5 Why-s" and "Cause Tree Analysis"

  • Practical exercise: Determining incident causes using the "5 Whys" and "Cause Tree Analysis"

• RCA: category methods:  "Ishikawa Fishbone" and SCAT (System Cause Analysis Technique)

  • Practical exercise: Determining incident causes using the "Ishikawa Fishbone Diagram" method

  • Practical exercise: Determining incident causes using the System Cause Analysis Technique method

• RCA: Barrier method “Bowtie”

  • Practical exercise: Determining incident causes using the Bowtie method

 

Element 4: Developing Corrective Actions and Learning from Incidents

• Forming conclusions, identifying missing, inadequate, or ineffective controls

• Developing effective corrective and preventive measures

• Practical exercise: Assessing the effectiveness of measures

• Creating an investigation report

• How to learn lessons from incidents effectively

  • Practical exercise: Creating lessons learned from an incident

  • Practical exercise: Reflective learning from incidents