Course 4: Incident Investigation/Root Cause Analysis Leadership

This course teaches how to lead investigations and root cause analyses using various techniques such as Causal Factor Charting, Fault Tree Analysis and Root Cause Charts. This is a “How To” course designed to teach skills. An optional part of the course can include 1 to 2 hours of software instruction.


$1,350.00 USD (per student) for 3-day version, Online

$1,350.00 USD (per student) for 3-day version, in USA

$1,995.00 USD (per student) for 3-day version, in Bahrain and Dubai, UAE

This course can also be taught (either as-is or customized) at your site. Please contact PII for details about having our training provided at your site.

Incident Investigation/Root Cause Analysis Leadership Course 4 (3-Day) | Process Improvement Institute

Recommended prerequisites: Participants should have practical, technical experience in design, operation, or maintenance of complex systems. Individuals with good logic skills do best in this course. Course 10 is especially helpful, but not required.

Typical Course Candidates

  • Engineers – process, process safety, and mechanical
  • Operations and Maintenance Staff – senior operators, maintenance technicians, supervisors
  • Process reliability staff
  • Process quality control/assurance staff

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
    • 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
  • 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

Take Home:

  • Comprehensive course notebook containing
    • Root Cause Chart™
    • Industry examples and solutions
    • A 65-page Root Cause Analysis Guide that includes details on the use of the Root Cause Chart™
  • Electronic (PDF) copy of course notebook, including the Toolkit and Root Cause Chart™
  • Free Excel worksheet for documenting causal factor charts and fault trees
  • Certificate of Completion
  • 2.0 CEUs & 2.0 COCs

Day 1 (8:00 a.m. to 5:00 p.m.)

  • 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 (8:00 a.m. to 5:00 p.m.)

  • 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

Day 3 (8:00 a.m. to 3:30 p.m.)

  • 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)

Bill BridgesBill Bridges is the primary instructor for this course. He has trained over 3000 investigators during the past 17 years of teaching this topic. And he has led over 100 major investigations of chemical and industrial accidents. He co-authored the definitive textbook on this topic by AIChE, Guidelines for Investigation of Incidents in the Chemical Industry, 2nd edition, 2003. To find our more about this course or to check into having this course taught at your site, contact Mr. Bridges at 1.865.675.3458 or by e-mail at

Revonda TewRevonda Tew is a co-instructor for this course. She has many years of PSM implementation experience, led many investigations and participated in many others, and she has considerable training experience. Feel free to contact Mrs. Tew at