When “Human Error” isn’t enough: Successful Failure Investigation
2/3 September 2026, Copenhagen, Denmark
Course No. 22618
Speakers
Energy Kristina Hansen
MilCor Consulting
Tim Ohlrich
gempex
Wolfgang Schmitt
CONCEPT HEIDELBERG
Target Group
Personnel involved in failure investigations and root cause analysis (RCA)
Quality Assurance professionals responsible for deviation management and CAPA
Anyone contributing to or reviewing event, deviation, or CAPA management within the organisation
Objectives
Understand fundamental principles of effective failure Investigation
Learn to distinguish true root causes from causes and symptoms such as “human error”
Explore structured tools and methodologies
Background
Things will go wrong from time to time. In the world of pharmaceuticals, we need to ensure that we have robust processes and procedures in place to deal with such situations. When an unplanned event arises, it must be handled accordingly.
1.4 (xiv): “An appropriate level of root cause analysis should be applied during the investigation of deviations, suspected product defects and other problems.”
In any case a sound failure investigation is the key to identify appropriate actions and CAPAs. Here, understanding how to handle both human error- and non-human error-based non-conformances is crucial.
1.8: […] “The basic requirements of GMP are that: (vii) Any significant deviations are fully recorded, investigated with the objective of determining the root cause and appropriate corrective and preventive action implemented”
Root cause analysis (RCA) is a process that attempts to identify the exact cause of a problem, such as a deviation. Only by identifying the exact underlying fault it is possible to take the right action to solve the problem and prevent it from occurring again.
Programme
Kick-off: When it’s human
Expectations on Humans
Why human error could not be a root cause
Blame culture vs. Root Cause
Error Culture
Excerpt from FDA Warning Letter “…the investigation failed to establish a root cause and your quality unit failed to ensure the implementation of adequate corrective actions to prevent future recurrence.”
Presentation and Workshop: Using 5 Whys and Ishikawa
Short Introduction of the methods
Strengths and weaknesses of each method
Typical mistakes in application
Workshop: Real life examples and experiences
Interactive Session: Comparative Analysis
Identifying and documenting errors with worksheets
The need for a systematic approach
The key for success: comparison of occurred deviations with available facts
Bow-Tie Risk Management and Problem Solving Analysis
Controls, connection and causality
Risk velocity
Preventive, detective and corrective controls
The link to Fault Tree Analysis and Event Tree Analysis
Interactive Session: A3 Methodology
What is a problem?
The causes investigation; point of cause, direct cause and root cause
The 8-steps, structure and methodology
Deep Dive: Point of cause analysis
Solving a murder case
Human Error Related Deviations
The What - Top 10 Categories: FDA Warning Letters (2021-2022) - The commonality - Undesirable behaviour…what is it?
The How - The KAP model - Factor in the social element
The Recurrence - Human Error is NEVER a root cause - Blame it on the culture
Behavioural Root Cause Analysis (bRCA) for Human Error Related Deviations (HErD)
Behavioural Root Cause Analysis tool (3B Method)
Theory behind 3B method - Informative construct (brain)
Utilize the solution - Sort the HErD: 3B Method - Practice in groups
RCA Completion
How to document a Root Cause Analysis
How to define the right actions based on the outcome
Deviation Management and CAPA Principles and all relevant aspects to implement, improve and/ or work with a Deviation Management and CAPA System are topic of ECA’s Deviation Management and CAPA training course. For more information see www.gmp-compliance.org/ or send an e-mail to w.schmitt@concept-heidelberg.de.
Accommodation CONCEPT HEIDELBERG has reserved a limited number of rooms in the conference hotel. You will receive a room reservation form when you have registered for the course. Reservation should be made directly with the hotel. Early reservation is recommended.
Get-Together On 2 September you are cordially invited to a Get-Together. This is an excellent opportunity to share your experiences with colleagues from other companies in a relaxed atmosphere.
Fees (per delegate plus VAT) ECA Members EUR 1,890 APIC Members EUR 1,990 (does not include ECA Membership) Non-ECA Members EUR 2,090 EU GMP Inspectorates EUR 1,045 The conference fee is payable in advance after receipt of invoice and includes lunch on both days, dinner on day 1 and all refreshments. VAT is reclaimable.
Presentations/Certificate The presentations for this event will be available for you to download and print before and after the event. Please note that no printed materials will be handed out on site and that there will not be any opportunity to print the presentations on site. After the event, you will automatically receive your certificate of participation.
Conference language The official conference language will be English.
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