INCIDENT INVESTIGATION AND MANAGEMENT (Incl. Root Cause Analysis) WORKSHOP
5 - 6 March 2019
SAIEE HOUSE, 18a Gill street, Observatory, Johannesburg, 2198
Non-member R7,500, SAIEE Member R5,500
AMEU Mem. Rate: R6,800
NOTE: If proof of payment is received before the commencement of the course, the following rates will apply:
Non-Member R6,750, SAIEE Member R4,950
PLEASE SUBMIT THE ATTACHED REGISTRATION FORM BY 16:00 ON THE 26/02/2019
All equipment has one thing in common - at some point in its life it will fail. Often the failure results in major losses to the organisation! So it needs to be investigated – to ensure that it never happens again. Most engineers believe they can this properly but in practice few are really good at it.
This course teaches engineers, technologists and technicians how to carry out an excellent investigation, so that they can assure management that “it will never happen again!”
Fascinating case studies of actual major incidents like the Titanic, Concorde, and Chernobyl disasters are used to illustrate the approach required for effective investigation.
The real Root Cause must be determined, and an effective corrective action implemented.
Several excellent Root Cause analysis techniques are shown, including Fish-bone, 5 Why’s, and the Why Staircase. So make sure you are competent to perform this duty by attending this very interesting two-day course.
• Introduction, course objectives, incidents
• Incident management, definitions
• Process for effective incident management, procedure immediately following incident
• Initial notification of incident, incident classification : Exercise 1 – Koeberg generator bolt
• Preservation of site, appointment of Investigation Team
• Investigation of incidents, fundamental problem definition, information collection, sequence of events, causal analysis, determine contributory and root causes, root cause analysis, Ishikawa (Fishbone)
• Exercise 2 – Titanic
• Determine corrective actions : Exercise 3 – the German High-Speed Train crash
• Develop action plan : Exercise 4 – the Titanic Action Plan, case study – Kriel generator synchronized out-of-phase
• Exercise 5 – the Piper alpha oil rig fire : recommendations
• Exercise 6 – the Space Shuttle challenger, repeat incidents, similar plants, discussions with management
• Compile the report, the Investigation Report, professional report writing, the important sections, after the investigation, implementation of corrective actions, testing effectiveness of corrective actions
• Close-out of incident : Exercise 7 – The Concorde
• Final aspects, operational experience, trending and analysis, dealing with common problems, audit of system : Exercise 8 – American Airlines Flight 191
• Final exercise – Chernobyl
This course is aimed at managers and engineers at all levels - from assistants to chiefs, as all will or should get involved in important technical investigations from time to time.
Upon completion of this course, you will receive 2 CPD Credits under validation number SAIEE-1124-V
A retired power plant engineer / manager with 32 years of experience in ESKOM in the commissioning, operating, engineering and managing of several of their power stations. As Technical manager at their largest station, Kendal, he was directly involved in improving the station’s technical performance from 'worst in Eskom' to 'BEST IN THE WORLD'. He now develops and presents courses on improving technical performance to many young engineers, technologists and technicians.