This practical and highly-interactive course includes various practical sessions and exercises. Theory learnt will be applied using our state-of-the-art simulators. A high percentage of incidents are caused by human error and lack of proper training. The number of such incidents may be greatly reduced by thorough investigation of incidents, establishing root causes, implementing effective corrective and preventative actions. This course is designed to introduce the attendees to established methods, of achieving this in a structured and proven manner. Root cause analysis is simply a tool designed to help investigators (1) describe WHAT happened during a particular occurrence, (2) determine HOW it happened and (3) understand WHY it happened. Only when investigators are able to determine WHY an event or failure occurred will they be able to specify workable corrective measures. Most event analysis systems allow investigators to answer questions about what happened during an event and about how the event occurred, but often they are not encouraged to determine why the event occurred. Generally, mistakes do not “just happen”. They can be traced to some well-defined causes. 
 When the analysis stops at the point of answering WHAT and HOW, the recommendations for preventing recurrence of the event may be deficient. Investigations that probe more deeply into WHY the error occurred are able to provide more specific, concrete and effective recommendations. The root cause analysis presented in this course is designed for use in investigating and categorizing the root causes of events with safety, health, environmental, quality, reliability and production impacts, although the exercises and case studies used in this course are predominantly those having safety and health impacts.