Cause Analysis Template

• Prepared by

• Other managers participating in the investigation:

• Conducted on

  Date

• Restaurant

  Select Newark West Chester Media Wilmington North Wales Phoenixville Lancaster Maple Shade Chestnut Hill HQ

  • Newark
  • West Chester
  • Media
  • Wilmington
  • North Wales
  • Phoenixville
  • Lancaster
  • Maple Shade
  • Chestnut Hill
  • HQ

• How to use this form: After an accident, analyze how this accident was caused and how it could have been prevented. Then come up with an action plan of steps to take to prevent such accidents in the future. This form is filled out by the manager, NOT with NOT BY the injured guest or employee.
  
  This form may contain information relating to guest or employee health or other private concerns and must be used in a manner that protects their privacy, if at all possble.

• Details of issue requiring a root cause analysis

• Date issue recorded

  Date

What caused the issue (Check all that apply)

• Physical causes (Select all that apply)

  Select poor supervision lack of training staff not following written practices circumstances not covered in current training

  • poor supervision
  • lack of training
  • staff not following written practices
  • circumstances not covered in current training

• Hazard (select all that apply)

  Select Created by coworker Created by external factors Documented but not repaired Conditions changed without proper communicaiton

  • Created by coworker
  • Created by external factors
  • Documented but not repaired
  • Conditions changed without proper communicaiton

• Procedures

  Select Not developed or developed but not accurate Developed but not followed Followed procedure, but did not understand it properly leading to incident

  • Not developed or developed but not accurate
  • Developed but not followed
  • Followed procedure, but did not understand it properly leading to incident

• Training

  Select Inadequate instruction or training Circumstances not addressed in training

  • Inadequate instruction or training
  • Circumstances not addressed in training

• Unsafe behaviors

  Select 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 tool or equipment Unable to physically perform work Horseplay, joking around

  • 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 tool or equipment
  • Unable to physically perform work
  • Horseplay, joking around

• Communication

  Select Insufficient planning Breakdown in communication between workers Breakdown in communication between workers and managers Breakdown in communication between teams Confusion after communincation

  • Insufficient planning
  • Breakdown in communication between workers
  • Breakdown in communication between workers and managers
  • Breakdown in communication between teams
  • Confusion after communincation

• In a hurry (Please select all that apply)

  Select Supervisor implied need Employee perceived need Customer originated Friendly competition Understaffed, lack of assistance when needed Workload too heavy

  • Supervisor implied need
  • Employee perceived need
  • Customer originated
  • Friendly competition
  • Understaffed, lack of assistance when needed
  • Workload too heavy

• Other (describe):

Can you think of anything else that might have contributed to causing this injury? List all other possible contributing factors. (long hours, weather, change in process, etc.) Please dig deep to try to discover the actual root cause. One technique is to ask a series of 'why'' questions to get at the basic root cause.

• Please describe all that you have discovered about what occured.

• Add signature

  Sign

• Take pictures of anything that would add clarity the the explanation, show a condition that needs to be fixed, etc.

  Media

• ATTACH: The original report, photos, witness statements, signatures of completion of training, relevant policies, etc. Anything that would help us determine the root cause.
  
  SEND to: GM, RM, Lorraine Serva (Safety Committee), Lori Thomas

Recommended Corrective Actions To Prevent Future Injury

• Think about all possible corrective actions including but not limited to changing or improving: operations procedures, training, personal protective equipment, policies, cleaning products, communications, etc.
  
  For example:
  “cutting gloves have been purchased for employees using knives, and employees need to be instructed on the use of the gloves, and managers need to enforce use of the gloves.”
  “checked to see that a ladder of the correct height was available to change lightbulbs and will instruct all FOH employees on use of ladders during pre-shift meetings this week.”
  “will sign employee up for Back Injury Prevention class, and will instruct all new employees how to safely transport multiple glass racks before they begin their job.”
  “will call janitor and ask them to use a floor degreaser on a regular basis, will place a mat at the transition point from slate to wood.”
  

• 1. Describe first recommendation for corrective action:

• Issue Will Be Corrected by

  Date

• Person responsible for ensuring corrective action is completed:

• 2. Describe second recommendation for corrective action:

• Issue will be corrected by:

  Date

• Person responsible for ensuring corrective action is completed:

• Describe third recommendation for corrective action:

• Issue will be corrected by:

  Date

• Person responsible for ensuring corrective action is completed: