Courses

At two in the morning, a leak during maintenance ignites and two technicians are injured. It could have been much worse. In this advanced course you learn to lead the investigation of major and high-potential incidents: classify by the worst credible outcome, set terms of reference and an independent team, manage physical, electronic and documentary evidence with a chain of custody, conduct cognitive interviews, build detailed timelines, events and causal factors charts and change analyses, analyse barriers with a retrospective bow-tie and the definitions of IOGP Report 544, identify human and organisational factors (Reason's model, local rationality, systemic methods) and turn the conclusions into robust recommendations and organisational learning. Aligned with HSG245, the guidance of the British health and safety regulator, as a good practice reference. Continuous case at a fictitious gas treatment plant. Assumes the foundation of course SST-202. The course is delivered in Portuguese.

What you will learn

• Classify incidents by potential and organise a major incident investigation, with terms of reference, independence and a suitable team.
• Manage the physical, electronic and documentary evidence of a complex investigation, with a chain of custody, testing and cognitive interviews.
• Build detailed timelines, events and causal factors charts and change analyses.
• Analyse failed, degraded, missing and effective barriers with a retrospective bow-tie.
• Identify human and organisational factors in a major incident without stopping at human error.
• Formulate robust recommendations, communicate the results and verify their effectiveness as organisational learning.

Modules

1. Major and high-potential incidents79 min
2. Managing the investigation and the evidence80 min
3. Timelines and event analysis86 min
4. Barrier analysis and bow-tie78 min
5. Human and organisational factors77 min
6. Recommendations and organisational learning80 min

Who it is for

Lead investigators, HSE coordinators and managers