This course is aimed at investigating – analysing – understanding and developing mitigations for the incidents accidents and safety occurrences which are faced on a regular basis within our organisation.
Such incidents do not necessarily lead directly to significant negative outcomes, however may become a precursor or element of a future event. We have an opportunity to subject such safety occurrences to correct and proper investigation and analysis, in this way they may have a significant and beneficial effect on the organisations ability to improve its safety performance.
DETAILED CONTENT / TOPICS (the following subjects will be addressed) -
- Regulatory, Industry and Business Drivers influencing our SMS
- Developing an Acceptable level of Safety Performance – Defining minimum Safety objectives
- Reviewing Safety Oversight Mechanisms
- Investigation and Analysis Considering Risk and Exposure – When to Perform Investigations
- Considering the SMS mandatory obligations and our follow up activities
- Roles and Responsibilities
- How to Implement, Develop and Optimise our Internal Reporting Mechanisms
- How to Maximise the Effect of Confidential Reporting – How Beneficial is Confidential Reporting?
Investigations – Structure & Preparation:
- Considering Investigator competence
- What level of investigation is appropriate – Measuring exposure and return on investment?
- Internal / External – Jurisdiction and Legal Considerations
- Investigator Responsibilities and Reporting Obligations
- Pre-requisites and preparations – individual and organisation perspectives
Sources of Information:
- Considering the Information available to the SMS
- Discussion regarding the aims and benefits of information collection
- How to effectively manage information -how to filter & process?
- Validity of Information – how long is information effective
Carrying out Interviews:
- Preparation before the interview
- Interview techniques for best results
- Environmental Considerations
- Effective Human Interaction – Knowledge test – qualifying the witness
- Witness testimony
- Feed back and Communication – Verification for Positive outcome
- Case Study 1 – Team Activity followed by Group Debrief
- Information evaluation to a standard
- Data and information organization and analysis. Structured Analysis
- Practical understanding of the role of Root Cause
- Identification of Root Cause
- Managing Root Cause Processes including Analysis
- Analysis using Logic Models and Simulations introduction
- The Role of Quantitative and Qualitative processes
- Developing Preventative Strategies and the role of Performance Auditing
Building a Timeline:
- Constructing the event time line which will support analysis
- Further investigation process derived from the time line
- Consider the “Why” together with the organisational factors involved
- Choosing the Investigation model to support this event
- Consider the bias which may be present and how we can discount
CRM an HF Considerations:
- How to develop a HF understanding within the environment of our investigation and to understand where the exposures exist
- Consider mitigations which may remove the exposures introduced by HF / CRM considerations
- Consider the pre cursors to errors and the connection with personal and organisationally optimising violations
Risk Analysis and Management:
- Explores the concept of risk as a matter of perspective, and the interaction of consequences and likelihood to determine risk.
- How we Measure and Categorize Risk
Fishbone & Bowtie Analysis:
- Discusses the Tolerability and Acceptability of Risk to an Organization
- ARMS – Additional Considerations Understanding the Stages of Effectively Managing and Measuring Risk
- Delivering Safety Improvements through Cultural Change
- Developing Mitigations and Safety Improvements
- Considering the responsibility for managing Risk within the Organisation
- The responsibility of the Investigator to develop and present proposed mitigations
- The responsibility of the business area owner to consider mitigation proposals and to take the appropriate actions.
Reporting and Documenting Outcomes:
- Generating Reports in an appropriate format taking into account the needs of the recipient
- Structure and Content of the Report
- Team based activity involving all elements of the process, extensive, interactive and practical, producing a detailed investigation report to present to the responsible person with full justification of processes, methods and conclusions.
- Debrief and Close out
TARGET GROUPS -
Safety and Quality Audit staff, Members of the safety action group, safety experts, SMS stake holders.
A strong understanding of QMS, SMS and organisational processes.
LEARNING OBJECTIVES -
After completion of this course, Delegates should be able to perform all steps necessary to perform appropriate investigations and analysis, and will be equipped to apply those skills in a practical way and propose mitigation within their organisation.
5 Days – Each day will commence at 09.00 and finish at 17.00, with appropriate refreshment breaks.
To register for this training, please email firstname.lastname@example.org or Call +359 28210806