• To understand and appreciate the purpose of Incident Investigations.
• To value the benefits of conducting an in depth investigation.
• To educate participants on the value and importance of Incident Investigation and their role to assist the investigators by providing correct information.
No Pre-requisites.
• Why we need to do an incident investigation
• The processes of incident investigation
• IMO recommended casualty investigation & In house company investigation
• Who should form part of the investigation team
• Importance of gathering facts
• The type of facts Physical, Human and System
• Analysis of facts gathered Determining Root Cause(s)
o 5 WHY
o Fish Bone
o Current Reality Tree
o Barrier Analysis
o System Bases RCA
• Recommendations
• Closure of recommendations
• Reporting
• Horizontal deployment of lessons learnt across the fleet/across the industry
