5 WHY Incident Investigation

• Incident description

• Conducted on

  Date

• Prepared by

1. INVESTIGATIVE TEAM MEMBERS

• Names of investigative team

2. IMPORTANT

• Has drug and alcohol test been arranged?

  Yes

  No

  N/A

3. INCIDENT DETAILS

• Incident Type

  Select Near Miss Personal Injury Environmental Equipment Damage / Process Loss First Aid

  • Near Miss
  • Personal Injury
  • Environmental
  • Equipment Damage / Process Loss
  • First Aid

• Date and time of incident

  Date

• Vessel or Location of incident

• Other - List

• Person(s) involved

• Plant / Equipment involved

• Injuries / Damage sustained

4. EVIDENCE

• Photographs

  Media

Statement

• Statement

• Signature of person if giving statement

  Sign

5. 5 WHY

• 1. Why did the incident happen?

• Supporting data

• 2. Why did 1 happen?

• Supporting data

• 3. Why did 2 happen

• Supporting data

• 4. Why did 3 happen?

• Supporting data

• 5. (Optional) Why did 4 happen?

• Supporting data

6. ROOT CAUSE (What was the answer to the last question?)

• Enter root cause?

Root cause

• Root Cause

  Select Risk Assessment Procedure Design Quality Control Maintenance Human Factors Management Training Communication Environmental Other - List Below

  • Risk Assessment
  • Procedure
  • Design
  • Quality Control
  • Maintenance
  • Human Factors
  • Management
  • Training
  • Communication
  • Environmental
  • Other - List Below

3 Components of the Risk

• What hazards are associated with the incident (moving parts, sharp objects, flying debris, etc...)

• Is there an employee behavior/act that contributed to the incident

  Yes

  No

  N/A

• What was the behavior/act

  Yes

  No

  N/A

• Were there control systems in place (training, guarding, procedures...)

  Yes

  No

  N/A

• What are the controlled systems and can any be improved

7. RECOMMENDATIONS

• Any recommendations