Incident Investigation & Root Cause Analysis (RCA)

1. Incident Investigation Fundamentals

• Purpose of incident investigation
  
  
• Types of incidents: accidents, near misses, unsafe acts
  
  
• Legal, ethical, and organizational expectations
  
  

2. Incident Causation & Human Factors

• Accident causation models
  
  
• Human error vs system failure
  
  
• Organizational and cultural influences
  
  

3. Evidence Collection & Fact Finding

• Securing the scene safely
  
  
• Interviewing witnesses effectively
  
  
• Collecting physical, documentary, and digital evidence
  
  
• Avoiding bias and assumptions
  
  

4. Root Cause Analysis Techniques

• 5 Whys method
  
  
• Fishbone (Ishikawa) analysis
  
  
• Fault Tree Analysis (FTA) – awareness
  
  
• Barrier and control failure analysis
  
  

5. Analyzing Findings & Determining Causes

• Immediate causes vs underlying causes
  
  
• Identifying failed controls and safeguards
  
  
• Linking causes to risk management gaps
  
  

6. Corrective & Preventive Actions (CAPA)

• Developing strong, sustainable actions
  
  
• Assigning ownership and timelines
  
  

Avoiding weak or superficial controls