Title Page
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Prepared by
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Location / Division
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Supervisors Name
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Department
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Today's Date
What Happened
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What are the details of the incident?
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What date did the incident occur?
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What area/service was impacted?
Was the proper procedures followed?
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What are the steps in the process, as they were designed?
What were the most approximate factors causing the Incident?
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Environmental factors - Soil, water, air or temperature a factor?
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Team member factor - Was time in current position a factor?
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Team member factor - Was frequency of activity a causing factor?
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Team member factor - Was lack of training a factor?
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Was the team member aware of their surroundings?
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Was time a factor - Time of day, shift?
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Is leadership a factor of the incident - Nature of supervisor?
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Is leadership a factor of the incident - Communication failure?
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People factor - Was the incident deliberately caused by the team member?
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People factor - Was the incident due to the team member not doing what they were told?
Why did it happen?
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Was the team member properly trained?
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Was staffing levels an issue?
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How could orientation and training be improved to help eliminate this type of incident?
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Is there proper communication between the team member and supervisors?
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If poor communication, how can it be improved?
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Was the incident due to equipment or equipment failure?
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If the incident was due to equipment what needs to be fixed?
Root Cause Number 1.
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What was the major root cause of the incident?
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Why did it happen?
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Why to the above answer
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Why to the above answer
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Why to the above answer
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Why to the above answer - This is the root cause for the number 1 cause of the incident!
Root Cause Number 2.
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Was there a second major cause of the incident?
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Why did it happen?
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Why do the above answer
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Why to the above answer
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Why to the above answer
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Why to the above answer - This is the root cause for the number 2 cause of the incident!
Corrective Action.
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What corrective action needs to be established to help eliminate this type of incident?
Pictures / Media as needed
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Attach any appropriate supporting pictures or media
Signature
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Enter your name for the signature
