Incident Investigation/Root Cause Analysis (RCA)

Incident Investigation/Root Cause Analysis (RCA) 2016-12-07T01:33:16+00:00

PII staff are experts in Incident Investigation (II) and Root Cause Analysis (RCA) consulting, and can assist or lead your organization in these processes. An incident investigation and root cause analysis (II/RCA) process should enhance organizational learning, reduce accidental losses, aid in wise investments of protective and mitigative systems, better protect people and equipment from harmGuidelines for Investigating Chemical Process Incidents and continuously improve Environment, Health and Safety (EHS) performance

Your company likely understands the criticality of getting near misses reported. With a good near miss reporting system, loss reductions of more than 90% have been achieved. However, not all near misses need full investigation. PII can help your company identify a system for determining which cases to fully investigate and save your company precious time and resources. One way to determine which cases to investigate is to let front line foremen or supervisors decide based on the apparent Learning Value of the incident. The foremen or supervisors can easily decide based on their hands-on experience. For high learning value incidents, investigate now. Low learning value incidents can be put in a database and investigated at a later date, if necessary.

Methodology

The overall II/RCA process consists of the following steps:

  • Data collection – collecting, organizing, and preserving all relevant data as quickly as possible after the incident has been stabilized. Data comes in the form of personnel interviews, physical evidence, and documentation.
  • Causal factor analysis – organize and analyze data to determine what happened (i.e., determine the chain of events
    [causal factors] that led to an undesirable occurrence)
  • Root cause analysis – For each identified causal factor, use a combination of the “5 Whys” and a Root Cause ChartTM (derived from the management oversight and risk tree process developed for US DOE’s Savannah River Laboratory) and step down to find the root cause(s).
  • Develop recommendations – develop recommendations to remedy each root cause of each causal factor
  • Reporting and follow through – Simplify the reporting of the investigation/RCA results to the bare minimum needed

PII can help your organization perform II/RCA assessments at various levels or settings, including:

  1. Coach newly trained II/RCA leaders
  2. Lead an independent investigation to ensure you are getting all the problems at your facility

PII also offers courses related to II/RCA (see courses 4 and 4-0 under “Training” or click on the links below):

Incident Investigator/Root Cause Analyst Training (3-day)

Incident Investigator/Root Cause Analyst Training (1-Day)

In addition, feel free to download papers written by PII staff related to II/RCA under the “Free Resources” tab (or click on the individual links below):

Proven Approach to Investigating Near Misses

Exxon’s Worldwide Incident Investigation Training

Gains from Getting Near Misses Reported

Why Choose PII?

Customization to Client’s Needs PII finds the best approaches to Incident Investigation and Root Cause Analysis to fit your specific needs and company culture. We deliver the highest value of service by customizing what we do to each client’s need.

Industrial experience of our providers Each of PII’s experts has many years of implementation experience as they worked in the chemical and related industries before becoming consultants and external trainers. Many other consulting companies will sell you services and training from “experts” who have only ever been consultants. This is of little value to you compared to using consultants and trainers who have learned what works and doesn’t work by actual experience in settings similar to yours.

PII Conducts Meetings with Speed & Efficiency. Because of our vast experience spanning 25+ years of performing IIs/RCAs, and with our hands-on expertise in the best software, we can lead meetings faster than anyone else, while maintaining quality/thoroughness. This saves cost for you and your projects.

PII Credentials

  • PII staff have trained over 3000 investigators during the past 17 years of teaching this topic.
  • PII staff have led over 100 major investigations of chemical and industrial accidents.
  • William Bridges, President of PII, co-authored the definitive textbook on this topic by AIChE, Guidelines for Investigation of Incidents in the Chemical Industry, 2nd edition, 2003.
  • PII staff members William Bridges (President), Greg Smith, Gerald Burch and Revonda Tew co-authored the paper “Proven Approach to Investigating Near Misses” which was prepared for presentation at the 9th Global Congress on Process Safety in San Antonio, TX, April 2013
  • PII President William Bridges wrote the paper “Gains from Getting Near Misses Reported” which was prepared for presentation at the 8th Global Congress on Process Safety in San Antonio, TX, April 2012