Accident investigation / Root Cause Analysis

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location

• Add media

  Media

• Date of Incident

• Time Of Incident

• Employee Name

• Employee experience overall

• Company experience

• Employee position

• Employee date of birth

• What task was being performed, how did the incident/accident happen,what was the result of incident/accident?

• Describe any tools, machinery, equipment, or PPE that was being used at the time of incident

• Was employee working alone?

  Yes

  No

  N/A

Step 1

• Obtain and review physical evidence, employee and witness information, and paper evidence pertinent to the investigation

• Witness name

• Employee / witness statements

• Evidence

  Media

Step 2

• Direct cause, contributing cause, and root cause
  
  

Policies/Programes

• Not developed or inadequate

• Developed and communicated

• Developed-not communicated

• Developed - not followed/enforced

• Developed - Not understood

• Lack of disciplinary Policy

• Disciplinary Policy Not Enforced

Communication

• Insufficient Planing for task

• Lack of worker communication

• Lack of supervisor instruction

• Sufficient supervisor instruction

• Confusion after communication

• Lack of understanding task

• Work team breakdown

Hazards

• Unidentified or not recognized

• Known but not corrected

• Known but not reported

• Created by external factors

• Condition change not conveyed

• Equipment repaired deficiently

• PPE Not adequate or defective

Blood borne Pathogen

• Unaware / aware of air borne hazard

• Stuck with contaminated needle

• Client contact/exposure

• Employee contact/exposure

• Sharps container not available

• Improper cleanup

• Contaminated waste not labeled

Productivity Factors

• Heavy workload

• Tight schedule to complete task

• Long/unusual working hours

• Falsely perceived need to to hurry

• Staff assistance unavailable

• Staff assistance inadequate

• Changes in process

• Employee was sick

• On medication, drugs, alcohol factors

• Double shift

Work Behavior

• Shortcuts taken

• Deviations taken

• Special infrequent task

• Tool/Equipment used improperly

• History of accidents/incidents

• Disregard / refused to follow procedure

• Staff assistance required

• Horseplay

• Repetitive or physically demanding

• Going on/coming off vacation

Training

• Deficient Orientation training

• Deficient job specific training

• Insufficient training for new hire process or task

• Lack of supervisor follow-up or reinforcement

• Lack of supervisor training

• Lack of employee training

• Communication of expectations

• Communication of rules/policy

• Hazards overlooked in training

Environment

• Weather/temperature factors

• Poor Housekeeping

• Poor lighting

• Poor visibility

• Air quality

• Noise

• Visibility of labels/warning signs

• Visible and audible alarms

PPE

• Available

• Required

• Required PPE not used/worn

• Trained on how to use

• Adequate fit

• Not used adequately

• Poor condition

• Adequate for the job performed

• Lack of supervisor enforcement

Facilities / Equipment

• Poor facility design

• Poor/faulty equipment or design

• Poor workstation design

• Equipment not guarded

• Equipment repaired deficiently

• Lack of preventive maintenance

• Employee lack of knowledge

• Equipment failure

• Inadequate inspection timelines

Step 3

• From the categories above ,check the major cause or causes of the incident

• Policies/Procedures

• Training

• Facilities/equipment

• Blood borne Pathogens

• Communication

• Productivity

• Environment

• Hazards

• Work Behavior

• PPE

Step 4

• Why did this happen?

• Why?

• Why?

• Why?

• Why?

• How can this be prevented

Steps for corrective action and completion date

The following persons have participated in the investigation

• Employee

  Sign

• Safety Manager

  Sign

• Supervisor

  Sign

• Customer representative

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