Incident Investigation/ Root Cause Analysis Leadership

Transcription

1 Incident Investigation/ Root Cause Analysis Leadership 5 days In-House Training Program Presented by: Dr. Hussain Ahmed Introduction: An incident is an actual loss event or a near miss that should be investigated so that effective actions can be taken to prevent the same or similar losses from happening again. Incidents may have a negative impact on health, safety, reliability or company reputation. Causal factors are human errors or equipment problems that directly led to the loss event or allowed the consequences of the event to be more severe. Elimination of the causal factors will prevent recurrence of the losses or reduce the consequences of the event. Many "investigations" and "root cause analyses" simply identify these causal factors and make recommendations to correct them. This may prevent the same event from recurring, but if the root causes are not addressed, similar events are likely to happen in the future. The root causes of these causal factors must also be identified and corrected. Root causes are the management system weaknesses that allowed the causal factor to occur. Management systems are the processes a company has in place to control the work process and to encourage personnel to take the appropriate actions and discourage them from taking inappropriate actions. You Will Learn: How to meet regulatory requirements for incident investigations How to develop and implement a structured program - Designed for learning from incidents - Why and how to define misses

2 - How to train others to recognize and report incidents - Includes planning for trending of data How to initiate and conduct an investigation - Establishing an effective team quickly - Methods for collecting different types of data, including effective interviewing skills How and when to apply causal factor and root cause analysis for investigating process and non-process incidents - Includes event and condition charting (causal factor charting) - Filling data gaps using fault tree logic - 5-Whys technique for finding root causes - PII s Root Cause Chart for categorizing root causes How to develop appropriate recommendations to address root causes at various levels to avoid future incidents How to structure reports Via actual industry examples and workshops, learn key points and practice your new skills Course Outline Day 1 Basics of incidents and investigations Workshop: Identifying near misses (near hits) Initiating the investigation Gathering data - Basics - Gathering data from people - Gathering data from documentation, parts, and chemicals Workshop: Identifying key data needs Analyzing data for ALL causal factors Workshop: Causal factor charting Day 2 Bridging gaps in data Workshop: Using fault tree analysis to find all possible scenarios and determine the most likely one Determining ALL root causes of each causal factor Workshop: Identifying root causes using the Root Cause Chart technique Developing conclusions and recommendations Workshop: Conclusions and recommendations based on facts Overview of results trending Preparing for the Case Study

3 Day 3 Case Study: Using all rules and methods taught in class to investigate actual incident in real-time setting. Small teams will: - Determine data needs - Gather data (interview role-players, get data from computer control systems, etc.) - Use causal factor charting and fault trees to analyze data and determine ALL causal factors - Use PII s Root Cause Chart to determine the multiple root causes of each causal factor - Draft effective recommendations and make presentation to class Course examination (optional) Day 4 Understanding what caused the incident Preventing an incident from occurring again Preventing similar incident occurrences Improving the operation of the facility and the organization Satisfying stockholders such as regulators, the public and internal reviewers Gathering and organizing the needed data Analyzing the data to determine causal factors Identifying root causes of the event Developing effective recommendations Writing required reports Day 5 What is an incident? What are causal factors? What are root causes? o Near-Miss Investigation o Incident Classification o Data Trending Equipment Design Process Procedures Supervision Standards and Policies Training Communication Practices Maintenance Practices

4 Workshops Why and how to define near misses and how to institute a program to learn all you can from all incidents How to initiate an investigation and gather evidence How and when to apply powerful techniques for causal factor and root cause analysis (the heart of this course) for investigating process and nonprocess incidents How to avoid future incidents by developing appropriate recommendations to address root causes How to structure reports for optimum effectiveness The fundamentals of data trending that allow identification of systemic problem areas INSTRUCTOR Dr Hussain H Ahmed, MBE BSc, MSc, PhD, PGCE, MIChemE, MSPE Dr. Hussain Ahmed is International Team Manager with a large size technical College in the UK specialising in the development, management and delivery of a wide range of courses strongly related to Oil & Gas Industry, Petrochemical, Oil Refineries, Health & Safety, Environmental and Pollution Control. Qualifications 1. BSc in Petroleum Engineering, University of Baghdad 2. MSc in Multi-Phase flow in Oil & Gas Production, University of Strathclyde- Glasgow. 3. PhD in Hydraulic Fracturing of oil/gas reservoir, Heriot-Watt University, Edinburgh. 4. PGCE in FE/HE Education, University of Manchester Metropolitan 5. PG Dip in Management, University of Liverpool- UK. 6. BTEC certificate in Training, BTEC Network 7. FENTO certificate in Basic Skills & Key skills, Fento York 8. Diploma in Line management with ILM 9. certificate in occupational health & safety at work ncfe 10. certificate in Environment management System SQA Experience

5 Dr. Hussain has more than 12 years of industrial experience in the Oil & Gas industry in Europe and the Middle East (Iraq; Saudi Arabia; UAE). He also has experience for more than 9 years in teaching, training and learning consultancy. He also has about 6 years in team leading & management. Achievements Hussain developed, published & taught more than 21 training manuals related to specific processes in the chemical, petrochemical and oil & gas industries in the UK, Middle East, & North Africa in topics such as oil well drilling technology; oil production technology; oil movement and transport; Oil-well drilling & drilling fluids, water injection; gas lift and injection; enhanced oil recovery techniques; treatment of oily water, Oil & Gas Production Facilities, Safety courses, Health & Safety, Environmental courses, Energy saving, Oil refineries, Gas turbines; Steam Turbines; Pumps and compressors; Centrifugal compressors; Valves & oil pipelines, etc. Dr. Hussain provided tutorials support for a wide range of open & distance learning programmes, designed and taught to various Oil & Gas Industries. He has developed and taught several short training courses. Hussain also carried assessments of vocational competence to national standards aligned both to NVQ and oil company needs. Dr Ahmed delivered more than 43 training courses to major oil companies such as ARAMCo; Waha Oil Co; ENI- Oil Co; ADCO; ZADCo; NDC; ADGas; PDO; KPC; KNPC; SOC; CHEVRON; BP; B.Gas; Baker Hughes; FINA-TOTAL; ZUITENA Oil Co. QP; QAPCo; etc. In countries such as Libya; Egypt; Syria; Kuwait; UAE (Abu Dhabi) ; UAE (Dubai); Oman; Jordan; Saudi Arabia; Bahrain; Qatar; UK (London; Manchester; Aberdeen) Publications Dr. Hussain published and presented more that 19 technical papers and public lectures related to environmental and Petroleum issues. Global warming, Petroleum industry and environment, Environment and Engineers, Energy Saving, waste minimization, Renewable energy, effluent treatment, Health & Environment, Health & Safety at work, North Sea world oil, Oil in Iraq, Oil refineries, Industrial safety, etc. Memberships Dr. Hussain is the chairman (4 years) for Engineering & Science Society NW England. Member of several technical societies (SPE, IChemE, BIE, IRG, BIPA, etc.).

6 Dr. Hussain managed a private Weekend school in Manchester- UK for 4 years ( ) Dr. Hussain is a course team leader since 1998 (currently we have 18 tutors in the team) Rewards Several of Dr. Hussain's trainees won medal for excellence from City & Guilds London Institute on yearly basis during , which is a record. Dr. Hussain had established excellent links with both local and overseas industry in developing the training services for them. Dr. Hussain had won Halton College honour award in 1998 In 2000, Dr. Hussain nominated for tutor award NW England (DfEE). In 2003, Dr. Hussain received the medal for excellence and City & Guilds tutor award. In 2006; MBE award by her majesty the Queen of GB on the New Year Honours List for Services to Education & Training in the UK and Overseas. DfEE). In 2003, DR Ahmed received the medal for excellence and C&G tutor award.