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  • Root Cause Analysis

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    Imam Saja Dech
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    This document provides a toolbox for conducting root cause analyses of Level 1 and 2 incidents. It includes sections to describe what went wrong, the extent of injury or damage, and what could have been done to avoid the event. Causes are categorized as direct such as unsafe acts or conditions, and indirect such as human or job factors. Investigators are prompted to expand on identified causes and determine if the event involved human error, negligence, or a willful act. Root causes may involve a lack of planning, standards, or compliance. Finally, actions for the current situation are recommended.

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    This document provides a toolbox for conducting root cause analyses of Level 1 and 2 incidents. It includes sections to describe what went wrong, the extent of injury or damage, and what could have been done to avoid the event. Causes are categorized as direct such as unsafe acts or conditions, and indirect such as human or job factors. Investigators are prompted to expand on identified causes and determine if the event involved human error, negligence, or a willful act. Root causes may involve a lack of planning, standards, or compliance. Finally, actions for the current situation are recommended.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    331 views1 page

    Root Cause Analysis

    Uploaded by

    Imam Saja Dech
    This document provides a toolbox for conducting root cause analyses of Level 1 and 2 incidents. It includes sections to describe what went wrong, the extent of injury or damage, and what could have been done to avoid the event. Causes are categorized as direct such as unsafe acts or conditions, and indirect such as human or job factors. Investigators are prompted to expand on identified causes and determine if the event involved human error, negligence, or a willful act. Root causes may involve a lack of planning, standards, or compliance. Finally, actions for the current situation are recommended.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    MS-FR05089 ROOT CAUSE ANALYSIS TOOLBOX (to be used for Level 1 and Level 2 incident investigations)

    SYNERGI CASE & TITLE:

    What was the purpose of the What is the extent of the injury or What could we have done to avoid the
    What went wrong?
    operation that resulted in the incident damage? event?

    DIRECT CAUSES: UNSAFE INDIRECT CAUSES: HUMAN


    DIRECT CAUSES: UNSAFE ACTS INDIRECT CAUSES: JOB FACTORS
    CONDITIONS FACTORS
    ☐ Operating without authority ☐ Interpersonal conflict ☐ Bad motivation ☐ Insufficient supervision
    ☐ Removing safety devices ☐ Inadequate guards or barriers ☐ Physically inadequate ☐ Inadequate guidance or leadership
    ☐ Safety devices put out of action ☐ Lack of some protective ☐ Psychologically inadequate ☐ Inadequate design
    ☐ Using defective equipment equipment ☐ Lack of knowledge ☐ Inadequate maintenance
    ☐ Wrong use of equipment ☐ Defective tools or equipment ☐ Lack of skill ☐ Inadequate purchasing
    ☐ Working on running equipment ☐ Defective materials ☐ Lack of job experience ☐ Insufficient tools or equipment
    ☐ Improper lifting or task position ☐ Fire or explosion hazards ☐ Physical stress ☐ Inadequate work standards
    ☐ Improper loading or placement ☐ Extreme weather conditions ☐ Psychological stress ☐ Wear and tear
    ☐ Work or task carried out wrongly ☐ Noise exposure ☐ Abuse of tools or equipment
    ☐ Not using or inadequate use of ☐ Poor workplace layout
    PPE ☐ Inadequate or excessive lighting
    ☐ Inadequate communication ☐ Inadequate warning systems
    ☐ Ignoring protective measures ☐ High or low temperature extremes
    ☐ Careless act or horseplay ☐ Inadequate ventilation
    ☐ Under influence of drink or ☐ Poor housekeeping
    drugs ☐ Slippery under foot

    Expand on identified Unsafe Acts Expand on identified Unsafe Conditions Expand on identified Human Factors Expand on identified Job Factors

    Was this Human Error? Negligence?


    Why did we fail to detect this earlier? Why did we fail to detect this earlier? Why did we fail to detect this earlier?
    Reckless Conduct? Or a Willful Act?

    ROOT CAUSES
    (Select as appropriate and expand)

    LACK OF PLANNING LACK OF STANDARDS OR PROCEDURES LACK OF COMPLIANCE

    WHAT SHOULD WE DO NOW?


    (Synergi Actions)

    Document1 Page 1 of 1

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