Title Page
-
Location
-
RCA Team Leader
-
Conducted on
Root-Cause Analysis
Issue Details
-
Date issue reported
-
Brief description of the issue
-
Rate the impact of incident
-
Was there damage to property?
-
What is the value of the estimated damage?
-
Who is the associate('s) involved in incident?
-
What equipment were they operating (if any)
-
Was the associate sent out for post accident testing?
-
Why?
-
Was video saved of this incident?
-
Why?
-
Where photo's taken of the incident scene?
-
why?
Possible Root Cause
-
List potential reasons why the issue happened
CAUSE
-
Brief description of a cause
-
Rate probability as the root cause
-
What is the root cause of the issue?
-
Categorize the root cause of the issue
- Equipment Malfunction
- Process Error
- Distraction
- Environmental Factors
- Lack of communication
- Error Trap
- Training error
- Other
-
Please specify
Prevention Strategy
-
Solution to be implemented
-
Estimated cost
-
Are there special considerations?
-
Please specify
-
Are there incidental findings to be reviewed for corrective action?
-
Please specify
Completion
-
Full Name and Signature of RCA Team Leader
-
List RCA Team Members
MEMBER
-
Full Name and Signature