MN09
Course Contents
Module 1: Foundations of Problem Solving and RCA Planning
- Introduction to Root Cause Analysis: principles, benefits and terminology
- The logic of failure: how minor issues combine into major incidents
- Symptoms vs causes: overcoming the trap of superficial fixes
- Establishing investigation thresholds: when to initiate a formal RCA
- Defining the problem statement: clarity, scope and impact assessment
- Forming the investigation team: roles, skills and stakeholder representation
- Planning the investigation timeline, logistics and governance requirements
Module 2: Evidence Collection and Information Management
- Types of investigation evidence: physical, digital, position and people
- Securing the scene and preserving relevant evidence
- Collecting records, physical data and witness information
- Interviewing techniques and effective questioning
- Building timelines and event sequence diagrams
- Separating facts, assumptions, opinions and missing data
- Validating evidence and identifying information gaps
Module 3: Causal Analysis Tools and Techniques
- Five Whys and structured cause questioning
- Cause-and-effect and fishbone diagrams
- Event and causal factor charting
- Change analysis and barrier analysis
- Fault tree analysis and logical cause pathways
- Pareto analysis and prioritisation of recurring issues
- Selecting and combining RCA tools effectively
Module 4: Corrective Actions and Recurrence Prevention
- Developing actions linked to verified causes
- Action hierarchy and strength of control measures
- Elimination, engineering, administrative and human controls
- Failure mode and effects analysis for action review
- Mistake-proofing and error-tolerant process design
- Assigning owners, deadlines, resources and priorities
- Testing action effectiveness and preventing unintended risks
Module 5: Facilitation, Reporting and RCA Application
- Facilitating multidisciplinary RCA meetings
- Managing bias, disagreement and difficult discussions
- Documenting findings, evidence and causal reasoning
- Writing concise RCA reports and recommendations
- Presenting results to management and stakeholders
- Tracking actions, verification and lessons learned
- Integrated RCA case study and improvement planning
