Title Page
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Customer/Job
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Project Number
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Prepared by
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Date of Report
RCA Report Questions
Event Details
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In your own words list issues/events that occurred resulting in the failed project
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List Project Team Members
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Name of Team Leader
Select: YES, NO, or UNKNOWN.
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Was there any deviation from the standard installation procedure? (Ex. Cut and lugged BDFB cables outside of the maintenance window before properly measuring termination points)
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If YES, explain the deviation.
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If deviation occurred from the standard procedure, was it likely to have contributed to the adverse event?
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If YES, explain the contribution.
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Was there a human action or inaction that contributed to the adverse event?
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If YES, explain how the actions contributed.
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Was there a defect, malfunction, misuse of, or absence of equipment that contributed to this event?
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If YES, describe the equipment and how it appeared to contribute.
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Did the involved staff have the correct credentials and skills to carry out the tasks expected of them?
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If NO, explain the perceived inadequacy.
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Was the staff trained to carry out their expected responsibilities?
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If NO, explain the perceived inadequacy.
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Were the staffing levels considered adequate at the time of the incident?
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If NO, explain why.
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Was there any lack of communication or incomplete communication that contributed to or caused the adverse event?
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If YES, explain who, what and how it contributed.
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Were there any environmental factors that contributed to or caused the adverse event? (Ex. The ladder rack was blocked by HVAC unable to reach cables)
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If YES, explain what factors and how they contributed.
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Were there any organizational or leadership factors contribute to or cause the adverse event?
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If YES, explain what factors and how they contributed.
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Was there any lack of assessment or planning factors that contributed to or caused the adverse event?
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If YES, explain the factors and how they contributed.
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Were there any other factors that are considered relevant to the adverse event?
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Describe:
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Was there a root cause identified?
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If YES, explain the root cause.
Risk Reductions & Prevention
Risk Reduction and Prevention Strategies
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List the recommended actions planned to prevent a future occurrence of the adverse event.
Project Manager Section
Incidental Findings
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**THIS SECTION IS ONLY FOR THE PM TO FILL IN**
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List and explain any incidental findings that should be carefully reviewed for corrective action
APPROVAL – PM will review with relative parties
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Following all revisions the report should be signed by the team leader prior to submission.
Signatures
Team Member
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Signature of team member
Team Leader
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Signature of team leader
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I acknowledge that all information included in this report is considered confidential and is intended only to promote safety and reduce risk.
