By the end of this programme, participants will:
- Understand the principles and process of Root Cause Analysis (RCA) using the Tripod Beta method.
- Learn to identify and analyze the underlying causes of incidents and failures in complex systems.
- Apply Tripod Beta tools to assess and prevent recurring safety and operational issues.
- Develop the skills to create effective corrective actions based on root cause findings.
- Gain hands-on experience in using the Tripod Beta method through case studies and practical exercises.
- Enhance incident investigation capabilities to improve safety, reliability, and performance in industrial environments.
DAY 1
Introduction to Incident Investigation and Tripod Beta Methodology
- Understanding risk management in human systems
- Concept of organizational defenses and the Swiss cheese model of accident causation
- Overview of Sequentially Timed Event Plotting (STEP) and its construction rules
- The four key stages of a Tripod Beta investigation
- Defining key elements: Event, Agent, and Object
- Visualizing incidents through the Core Diagram
DAY 2
Barriers, Preconditions, and Root Causes
- Identifying barriers and their role in incident prevention within a system
- Examining the four states of barriers and their use in a Tripod Beta tree
- Exploring human errors and their relationship to immediate causes
- Defining preconditions and their placement within the Tripod Beta tree
- Identifying and positioning underlying causes in the Tripod Beta framework
- Analyzing causation paths and presenting them within the Tripod Beta tree
- Understanding basic risk factors in business processes
DAY 3
Remedial Actions, Reporting, and Evaluation
- Identifying key nodes on the Tripod Beta tree for applying remedial actions
- Applying Haddon’s Hierarchy of Barrier Effectiveness
- Assessing the cost-benefit relationship of different barriers
- Structuring and formatting incident reports
- Effectively communicating lessons learned across the organization
- Final assessment through testing
