Information
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Root Cause Analysis
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Investigation Conducted on
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Investigation prepared by (list all):
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Location
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After an accident please analyze how it could have been prevented. The form is filled out by the Safety Committee Representative or a manager. The injured guest or injured employee do NOT fill it out, although they provide information that helps you fill it out.
This form may contain information relating to guest or employee health and other privacy concens. It must be used in a manner that protects the confidentiality of the guest or employee to the fullest extent possible while still using the information needed for preventing similar incidents in the future. -
Name of injured guest or employee
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Tap to enter the date of the accident.
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Please describe all that you have discovered about what occurred. Ask 5 why's to attempt to discover the true root cause.
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Tap here to draw an illustration of the location or of what occured.
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Include any photos of the area or the problem. Include any photos that would help us better understand the incident.
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Stop here until you complete your investigation, including the 5 why's. Once you have completed the investigation and believe you have a good, fact-based understanding of what occured, then please complete the remainder of this form.
The 5 Why's worksheet is in Sharepoint.
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What did you discover caused the accident?
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Physical Sources
- Poorly maintained tools or equipment
- Poor housekeeping, slippery floor, or tripping hazard
- Unguarded equipment
- Crowded work environment
- Poor storage practices
- Personal protective equipment not available
- Cold or hot temperatures
- Insufficient lighting or ventilation
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Unsafe Behaviors
- Did not use assigned personal protective equipment
- Tools or equipment used incorrectly
- Did not follow rules or instructions
- Circumvented safety feature
- Used poorly maintained or broken tools or equipment
- Unable to physically perform work
- Horseplay, joking around
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Hazard
- Created by co-worker
- Created by external factor
- Documented but not repaired
- Conditions changed without proper communication
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Procedures
- Not developed or developed but not accurate
- Developed but not followed
- Followed developed procedure, but did not understand properly leading to incident
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Training
- Inadequate instruction or training
- Circumstances not addressed in training
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Communication
- Insufficient planning
- Breakdown in communication between workers
- Breakdown in communication between workers and managers
- Breakdown in communication between teams (eg FOH and BOH)
- Confusion after communication
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In a hurry
- supervisor implied need
- employee perceived need
- customer originated
- friendly competition
- understaffed, lack of assistance when needed
- workload too heavy
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Other (List all other contributing factors.)
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Attach witness statements, signatures of completion of training, relevant policies, etc.
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What are your recommendations? What steps should be taken in order to prevent similar injuries in the future? List all that apply. Please make sure to add the agreed upon actions to your restaurant's Action Item Log so that the Safety Committee can track them through to completion.
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Email to GM, RM, Lorraine Serva and Chelsea Stroud. lorraines@ironhillbrewery.com and chelseas@ironhillbrewery.com
