Course Objectives:

• Produce a documented investigation that identifies that root causes equipment and human performance problems
• Define analysis techniques

Course Outline

• Introduction
• Course objectives
• Root cause analysis process
• Understanding human behavior and performance:
•  History of human error.
•  Extent of human error.
• Human behavior versus human performance.
•  Case study – behavior/ performance
•  Aspects of human performance.
•  Skills/ knowledge/ information
• Environment
•  Motivation and incentive
• Extent of equipment error.
•  Design life vs. premature failure.
•  Failure analysis vs. Root cause failure analysis
• Task analysis:
•  Paper and pencil task analysis.

•  Objectives
•  Advantages
•  Limitations

• Walk-through task analysis

• Objectives.
• Advantages.
• Limitations.

• Change analysis:
• Technique-flow chart

• Advantages.
• Limitations
•  Symbol.

•  Protective barrier analysis:
•  Physical protective barriers.
•  Administrative protective barriers
• Defense-in-depth.
•  Event and root cause charting:
• Benefits
• Effectiveness
• Definitions
• Symbols.
• Cause and effect
• Advantages
• Limitations
• Exercise
• Interviewing

• Feedback
• Parts of the interview process
• Opening
• Questions.

Who Can Benefit?

• Engineers or supervisors working in the operation