Incident Investigation and Root Cause Analysis
How to investigate workplace incidents to find and fix underlying causes rather than blame, followed through the invented Harrowgate Foods after a forklift strikes a picker in the freezer of its distribution centre in Dartmouth, Nova Scotia: why investigate and what makes an investigation good, reporting to the Department and the WCB, securing the scene, gathering physical, documentary and electronic evidence, photographs, sketches and timelines, interviewing witnesses, human factors and types of error, the five whys and fishbone diagrams, causal factor charts, fault trees and barrier analysis, learning teams and Safety-II, corrective actions that work, and writing the report, with a capstone investigation of a chemical splash.
HSE-403 12 lessons · 4 h 25 min ▶ Video lessons coming soon
Offered by HSM University · Safety Training
This is the Canadian version of this course. See the American version.
What you'll learn
- Explain why organizations investigate incidents and near misses, and what makes an investigation fair, thorough and useful.
- Apply the incident reporting and notification duties to the Department of Labour, Skills and Immigration and the WCB in Nova Scotia.
- Respond to an incident in the right order: care for the injured, make the area safe, secure the scene and start the investigation.
- Gather and protect physical, documentary and electronic evidence, and judge what each piece of evidence can and cannot show.
- Record a scene with photographs, sketches and measurements, and build an accurate timeline from several sources.
- Plan and conduct fair, effective interviews with witnesses and the people involved, using open questions and cognitive interview techniques.
- Apply human factors thinking to classify errors and violations, and explain how workplace conditions shape the decisions people make.
- Use the five whys and fishbone diagrams to find causes, while avoiding their common pitfalls.
- Use causal factor charts, fault trees, barrier analysis and bow ties to analyze complex incidents.
- Explain learning teams and Safety-II approaches, and use them to learn from normal work as well as failure.
- Choose corrective actions using the hierarchy of controls and action strength, and write them so they are done and verified.
- Write a clear, blame-free investigation report, share lessons with different audiences and track actions to closure.
Course content
12 lessons · 4 h 25 min total · final exam
- 1 Why investigate and what makes an investigation good 23 min · quiz
- 2 Reporting and notification duties in Nova Scotia 22 min · quiz
- 3 Responding to an incident and securing the scene 22 min · quiz
- 4 Gathering physical, documentary and electronic evidence 22 min · quiz
- 5 Photographs, sketches and timelines 21 min · quiz
- 6 Interviewing witnesses and the people involved 23 min · quiz
- 7 Human factors and types of error 22 min · quiz
- 8 Root cause methods I: the five whys and fishbone diagrams 21 min · quiz
- 9 Root cause methods II: causal factor charts, fault trees and barrier analysis 22 min · quiz
- 10 Learning from normal work: learning teams and Safety-II investigations 22 min · quiz
- 11 Corrective actions that work 22 min · quiz
- 12 Writing the report, sharing lessons and a capstone investigation 23 min · quiz
- E Final exam 20 questions
Requirements
Recommended background. You can start any course at any time.
Description
How to investigate workplace incidents to find and fix underlying causes rather than blame, followed through the invented Harrowgate Foods after a forklift strikes a picker in the freezer of its distribution centre in Dartmouth, Nova Scotia: why investigate and what makes an investigation good, reporting to the Department and the WCB, securing the scene, gathering physical, documentary and electronic evidence, photographs, sketches and timelines, interviewing witnesses, human factors and types of error, the five whys and fishbone diagrams, causal factor charts, fault trees and barrier analysis, learning teams and Safety-II, corrective actions that work, and writing the report, with a capstone investigation of a chemical splash.