Root Cause Analysis


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Upcoming Course

Code Start Date End Date Location Cost Instructor Register
PST0345-201801  05 Feb 2018  08 Feb 2018  Kuala Lumpur, Malaysia  SGD 3195  Akhtar Quddus   Register
PST0345-201802  14 May 2018  17 May 2018  Bangkok, Thailand  SGD 3195  Akhtar Quddus   Register
PST0345-201803  29 Oct 2018  01 Nov 2018  Kuala Lumpur, Malaysia  SGD 3195  Akhtar Quddus   Register

Past Course

Code Start Date End Date Location Cost Instructor Register
        Akhtar Quddus 
        Akhtar Quddus 
        Akhtar Quddus 
        Akhtar Quddus 
        Aaron A. Zick, Ph.D. 
        Aaron A. Zick, Ph.D. 
        Aaron A. Zick, Ph.D. 
        Akhtar Quddus 
        Akhtar Quddus 
        Aaron A. Zick, Ph.D. 
        Aaron A. Zick, Ph.D. 
PST0345-201601  25 Jul 2016  28 Jul 2016  Kuala Lumpur, Malaysia  SGD 3195  Akhtar Quddus 
PST0345-201701  27 Mar 2017  30 Mar 2017  Kuala Lumpur, Malaysia  SGD 3195  Akhtar Quddus 
PST0345-201702  03 Oct 2017  06 Oct 2017  Kuala Lumpur, Malaysia  SGD 3195  Akhtar Quddus 

Most organizations have accident investigation procedures. However, these procedures are often based on a blame culture & do not inspire the investigator to nd & correct the defects in the management system (root causes) that allowed the hazards to exist & the accident to occur.


Several industries have adopted excellent accident investigation & analysis techniques. Competence in the application of modern accident/incident investigation tools will assist organizations to learn & to prevent the recurrence of accidents & to evaluate the extent & location of management defects (root-causes), which contributed to the accident event. A good analytical accident investigation is invaluable to achieve continuous improvement in an organization’s HSE performance.

Day 1

  • Adopting Accident Prevention strategy thru Risk Management
  • Understanding how accidents are caused
  • The process & system view of accidents & accident investigations
  • The need for & benets of Root Cause Analysis
  • Introductions, Expectations & Anticipations
  • Dening Incidents, Accidents, Near Misses, Dangerous Occurrences
  • Categorizing of Incidents according to nature & severity
  • Complying with the Legal Requirements for report ing & investigating accidents
  • Understanding Immediate, Underlying & Root causes & Causal Factors
  • The four stages of an Investigation Process
  • Case Study & Group Activity

Day 2

  • Video-based Case Study & Group discussions
  • The various sources & categories of evidence
  • Collecting & Preserving Evidence
  • Common Pitfalls in observations
  • Conguration & Levels of the investigation team
  • Immediate response in case of an accident
  • Emergency procedures, Crisis handling & loss minimization
  • Taking control of the scene (Immediate Response)
  • Eective practical interviewing tips & techniques
  • Role Play Group Exercises

Day 3

  • Analyzing evidence & information
  • Identifying immediate causes, root causes and system causes
  • Using CLC Charts for analysis
  • Using 5-Why & Fish-bone techniques to re-enforce CLC Analysis
  • Sifting and sorting evidence & information
  • Incident Timeline – Data Mapping
  • Understanding the problems using Building blocks
  • Identifying critical factors
  • Case Study & Group exercises

Day 4

  • An Overview of Root Cause Elimination
  • Understanding & applying the Hierarchy & symmetry of controls
  • Addressing the personal, job & organizational factors in the recommendations
  • Overview of Solution Implementation
  • Identifying human factors & Understanding Human Errors
  • Modifying & inuencing behaviors
  • Case Study & Group exercise
  • Corrective Measures, Recommendations
  • Developing an Implementation Plan & organizing for its Implementation
  • Report Writing
  • Action Tracking & Closure monitoring
  • Trend Analysis
  • Define the accident / incident event
  • Understand modern accident causation theories
  • Define all accident investigation and analysis stages
  • Carry out Initial actions in response to accident and incidents
  • Gather evidence and data relevant to the accident investigation
  • Interview witnesses
  • Analyze the role of human factors involvement in accident investigation
  • Compile accident reports and remedial action plans
  • Gain familiarity with modern accident analysis techniques
  • The use of accident investigations as a management audit tool
  • To locate and dene active human error, preconditions and root causes
  • Report writing and compilation

This workshop is intended for all staff roles in engineering, technical and supporting departments  with responsibility for ensuring safety in the workplace and for conducting, leading, reviewing and approving incident investigations.

Aaron A. Zick, Ph.D.

Founder and President

Biography


President, Zick Technologies (Since 10/93).

Petroleum engineering consulting and software development, specializing in the area of reservoir fluid phase behavior modeling. References available on request. Key achievements:

-Developed numerous equation-of-state and black-oil fluid characterizations for various major oil companies and as a sub-contractor for Pera A/S.

-Recommended phase behavior experimentation and modeling guidelines for several major oil companies.

-Wrote PhazeComp, a new, state-of-the-art program from Zick Technologies for equation-of-state phase behavior modeling, reservoir fluid characterization, and the robust, efficient calculation of minimum miscibility conditions.

-Wrote Streamz, unique Petrostreamz A/S software for translating, manipulating, and managing vast quantities of fluid stream information.

-Designed and helped write Pipe-It, unique Petrostreamz A/S software for managing and manipulating petroleum resources, processes, and projects.

-Taught numerous industry courses on phase behavior, equations of state, reservoir fluid characterization, and miscible gas injection processes.

-Designed and helped implement a new set of equation-of-state routines for the in-house reservoir simulator of a major oil company.

-Advised the architects of a major commercial reservoir simulator on ways to significantly improve their equation-of-state routines.

 

Director of Research, Reservoir Simulation Research Corporation (6/91–10/93).

Responsible for the research and development of more efficient, accurate, and reliable techniques for modeling reservoir fluid phase behavior within MORE® (a fully-compositional, equation-of-state reservoir simulator). Also responsible for improving three-dimensional visualization of reservoir simulator output, and for occasional consulting work. Key achievements:

-Designed and implemented new equation-of-state solution algorithms for MORE®, improving both efficiency and robustness while using less memory.

-Developed a powerful and flexible interface between MORE® and TECPLOT™ (three-dimensional surface contouring software from AMTEC Engineering).

 

Senior Principal Research Engineer, ARCO Oil and Gas Company (9/83–5/91).

Developed expertise in reservoir fluid phase behavior, phase behavior modeling, compositional reservoir simulation, and relative permeability modeling.  Designed and analyzed PVT experiments. Created equation-of-state reservoir fluid characterizations. Developed ARCO’s phase behavior modeling software and relative permeability modeling software. Helped develop several of ARCO’s compositional and limited compositional reservoir simulators. Key achievements:

-Discovered the true, condensing/vaporizing mechanism of oil displace­ment by enriched hydrocarbon gases.

-Represented ARCO on the Prudhoe Bay co-owners’ Enhanced Oil Recovery Task Force for the Prudhoe Bay Miscible Gas Project.

-Designed and analyzed most of the PVT and slim-tube experiments for the Prudhoe Bay Miscible Gas Project.

-Created the equation-of-state reservoir fluid characterization adopted by the operating companies for the Prudhoe Bay Miscible Gas Project.

-Developed the miscibility pressure correlations used by the facility operators for the Prudhoe Bay Miscible Gas Project.

-Developed EOSPHASE, a then state-of-the-art program for equation-of-state phase behavior modeling, reservoir fluid characterization, and the robust, efficient calculation of minimum miscibility conditions.

-Developed SLIMTUBE, a special-purpose, equation-of-state simulator for slim-tube displacements.

-Developed new, compositionally-consistent, three-phase relative perme­ability models for ARCO’s compositional simulators and wrote data-fitting software for those models.

-Developed the phase behavior and relative permeability routines for a new, limited compositional reservoir simulator and assisted on other aspects of it.

-Continually added improvements to various in-house reservoir simulators.

-Regularly taught in-house courses on the phase behavior of miscible gas displacement processes.

 

IMPORTANT PUBLICATIONS

A. A. Zick, “A Combined Condensing/Vaporizing Mechanism in the Displacement of Oil by Enriched Gases,” presented at the 61st Annual Technical Conference and Exhibition of the Society of Petroleum Engineers, New Orleans, LA (October, 1986).

D. E. Tang and A. A. Zick, “A New Limited Compositional Reservoir Simulator,” presented at the 12th SPE Symposium on Reservoir Simulation, New Orleans, LA (March, 1993).