Incident Investigation & Root Cause Analysis

• Date of Incident

  Date

• Name of Site

• Type of Incident

  Select Near Miss First Aid Auto Equipment Property Causey by Other

  • Near Miss
  • First Aid
  • Auto
  • Equipment
  • Property
  • Causey by Other

• Make / Model / or Serial Number

• Incident Reported within 24 Hours

  Yes

  No

  N/A

• Incident Frequency

  Once

  More than Once

• Specific Location of Incident

  Select Chemical / Mechanical Room Dumpster Area Electrical Room Tunnel Vacuum House XPT 2nd Mile

  • Chemical / Mechanical Room
  • Dumpster Area
  • Electrical Room
  • Tunnel
  • Vacuum House
  • XPT
  • 2nd Mile

• Team Member Length of Employment

  0 - 6 Months

  6 Months -1 Year

  1 Year - 3 Years

  3 years - 5 Years

  5 Years or More

• Site Leader

• Consultant

• Prepared by

• What was immediately done to stop the HAZARD?

• 1.1 Who Noticed the Challenge

  Select Site Leader ASL TL Customer Consultant Safety

  • Site Leader
  • ASL
  • TL
  • Customer
  • Consultant
  • Safety

• 1.2 Who is Negatively Impacted by the Incident

  Select Site Leader ASL TL Customer Consultant Safety

  • Site Leader
  • ASL
  • TL
  • Customer
  • Consultant
  • Safety

• 1.3 Were There Any Contributing Behavior(s) to the Incident

  Yes

  No

  N/A

• 1.4 Did the Incident have Any Exposure Condition(s)

  Yes

  No

  N/A

• 1.5 Is the Process Stable?

  Yes

  No

  N/A

Section 2.0 - Heinrich Quick Analysis Toolkit

• 2.1 Heinrich Toolkit (Select All That Apply)

  Select Awkward Lifting / Too Big / Heavy Beginning of Shift / End of Shift Caught Between Chance Taking / Unsafe Behavior Clutter / Trip Hazards Customer Driven / Lack of Planning / heavy Workload Failure to do the Right Thing Fatigue / Illness Fire Damage Front Collision Frustrated Hazard Created by External Forces (such as Contractor) Hit Against Impaired / Under the Influence In a Hurry / Perceived Need Lack of Protection / Wrong PPE Machine not Guarded Lack of Communication Lack of Safe Work / Faulty Equipment / Poor Design Lack of Training Negligence Poor Lighting Poorly Maintained Poor Body Position / Strain Rear Collision / Backing Up Slippery Surface Struck-by Unaware Uneven Surface Unsafe Design / Poor Layout / Lack of Space Water Damage Wrong Tool / Procedure New Process

  • Awkward Lifting / Too Big / Heavy
  • Beginning of Shift / End of Shift
  • Caught Between
  • Chance Taking / Unsafe Behavior
  • Clutter / Trip Hazards
  • Customer Driven / Lack of Planning / heavy Workload
  • Failure to do the Right Thing
  • Fatigue / Illness
  • Fire Damage
  • Front Collision
  • Frustrated
  • Hazard Created by External Forces (such as Contractor)
  • Hit Against
  • Impaired / Under the Influence
  • In a Hurry / Perceived Need
  • Lack of Protection / Wrong PPE
  • Machine not Guarded
  • Lack of Communication
  • Lack of Safe Work / Faulty Equipment / Poor Design
  • Lack of Training
  • Negligence
  • Poor Lighting
  • Poorly Maintained
  • Poor Body Position / Strain
  • Rear Collision / Backing Up
  • Slippery Surface
  • Struck-by
  • Unaware
  • Uneven Surface
  • Unsafe Design / Poor Layout / Lack of Space
  • Water Damage
  • Wrong Tool / Procedure
  • New Process

• 2.2 Picture(s) of Opportunities (If Necessary)

  Media

Section 3.0 - Cause Analysis

• 3.1 Major Causes

  Select Complacency Confusion After Instruction Defective Equipment Fatigue Faulty Materials Frustration Improper Method or Procedure Lack of Communication or Not Understood Training People (+ Behavior / - Behavior) Rushing

  • Complacency
  • Confusion After Instruction
  • Defective Equipment
  • Fatigue
  • Faulty Materials
  • Frustration
  • Improper Method or Procedure
  • Lack of Communication or Not Understood
  • Training
  • People (+ Behavior / - Behavior)
  • Rushing

• 3.2 Tail, Fishbone (Problem Statement - Description of Pain Points)

• 3.3 People (Fishbone Analysis)

• 3.4 Machine (Fishbone Analysis)

• 3.5 Method (Fishbone Analysis)

• 3.6 Materials (Fishbone Analysis)

• 3.7 Environment (Fishbone Analysis)

• 3.8 Measurement (Fishbone Analysis)

• 3.9 Head, Fishbone (Proposal Statement - Plan of action to reduce opportunity from happening again)

Section 4 - Why Analysis

• 4.1 Why did the team, team member, or process experience an interruption?

• 4.2 Why did the event occur?

• Developed - not followed/enforced

• 4.3 Why did the team, team member, or process experience an unsafe condition?

• 4.4 Why did the unsafe Behavior or Condition Exist?

• 4.5 Why was protection inadequate?

Section 5 - Corrective Action(s)

• 5.1 Describe how the challenge eliminate or reduce the hazard for Team Member protection.

• 5.2 If applicable, how will you engineer or “design" the hazard out of the process.

• 5.3 If applicable, how will you substitute the hazard or task?

• 5.4 If applicable, state the item(s) of Personal Protective Equipment that will be needed for Team Member protection.

• 5.5 Is training or refresher training required?

  Yes

  No

  N/A

• 5.6 Is Safety Coaching Required?

  Yes

  No

  N/A

• 5.7 Picture(s) of Corrective Action (If Necessary)

  Media