Painters USA Root Cause Analysis Worksheet

• Job site

• Prepared by

• Location of Incident:
  Address

Incident Investigation Information

• Date of Incident:

  Date

• Date of Investigation:

  Date

• Jobsite Location:

• Name of Employee involved

• Name of Employee or Employees involved:

Root Cause Analysis Worksheet

• Step 1 - Incident Event: Describe the incident (injury, illness, other losses). Describe the sequence of relevant events (prior-during-immediately after) incident.

• Step 2 - Identify the Direct Cause of the incident. What is the DIRECT CAUSE of the incident? The simplest answer is the best. THIS IS THE MOST IMPORTANT STEP IN THE PROCESS.

• Step 3 - Sequence of Events: Develop sequence of events from start to finish, based on interviews and physical evidence. Describe the events precisely as they happen.

• Step 4 - After the DIRECT cause, identify the primary surface cause. Was it a Hazardous Condition or Unsafe Behavior?

• Hazardous Condition:

• Unsafe Behavior:

• Step 5 - Event Analysis - The 5 Why Process: This step involves asking the 5 Whys (why, why, why, why, why). Begin with the basic direct cause of the incident. Start by asking the first why to the direct cause. One why uncovers one reason and generates another why.
  
  Determine indirect cause (Hazardous Condition and Unsafe Behavior) from the sequence of events.

• Why:

• Why:

• Why:

• Why:

• Why:

• 6 Step. Corrective Action: List the Corrective Action to avoid future occurrences.

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