Information
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Investigation No;
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Investigation Title;
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Site / Location
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Investigation commenced on:
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Report Prepared by:
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Location
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Personnel involved in investigation;
Root Cause Description
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The root cause of any accident/incidents is the most basic cause that can reasonably be identified and management had the control to fix.
Root Cause Analysis will;
Identify the system that failed;
Map the system to causation;
Identify the management failure;
Identify the root cause.
There are usually only Four Possibilities:
1. No system in place;
2. There is a system however, the System is poorly defined;
3. The defined System is adequate but was not correctly implemented;
4. System defined but not implemented at all.
Investigation Process
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Once notification of an accident or incident is received you are ready to undertake an investigation, the purpose of the investigation should be to;
a) Identify the system which failed;
b) Examine the system for problems;
c) Identify the root cause of the accident/incident.
You can use the checklist below as you go about your investigation. -
Investigation Process Checklist
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Collect Initial Data
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Collect Information about management systems.
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Collect information regarding Physical Controls.
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Collect information regarding behaviours.
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Examine worksite.
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Identify personnel involved.
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Identify equipment involved.
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Interview Staff/Witnesses.
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Examine documentation.
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Examine training records.
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Examine Health & Safety inspection reports.
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Conduct any required tests.
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Notes
Events
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Here you need to Depict Events using the five "W's" = (who, what, why, where, when) and identify the following;
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Causal Factors
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Factual Evidence
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Add media if relevant.
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Relationships
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Develop an Events & Causation chart using recognised technique.
eg - fish bone, fault tree, FMEA etc. -
Draw Chart
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Get chart
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Identify system which failed.
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Examine the system for problems.
Management Controls
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Policy
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Was a Policy in place?
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Was the policy adequate?<br>
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Planning
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Was there a plan in place?
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Was the plan implemented?
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Was the plan adequate?
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Control
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Who is responsible for the standard?
- Organisation
- Management
- Supervision
- Operative
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Was the responsibility re-assigned?
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Who to?
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Was it in accordance with the standard?
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Competence
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Is there a required standard?
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Was the standard adequate?
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Was the person/person competent?
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Why was the person not competent?
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Implementation
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Was the system specified?
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Was the system adequate?
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Was the system implemented?
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Was the system implemented to the required standard?<br>
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Communication
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Was the system communicated?
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Was the communication adequate?
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Was it in line with the standard?
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Cooperation
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Was a standard specified?
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Was it adiquate?
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Was there cooperation?
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Measuring
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Was there a standard for measuring the system?
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Was it effective?
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Were the measures in line with the standard?
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Reviewing
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Was there a system for reviewing?
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Was the system for reviewing adequate?
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Was the system reviewed?
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Were any reviews in line with the standard?
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Were any reviews in line with the standard?
Root Cause
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Root Cause
Remember The root cause is the most basic cause that can reasonably be identified and management had the control to fix. -
No system in place. There is nothing in place to address this particular risk.
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System is adequate but no correctly implemented. There is a system defined, but this is not what was implemented.
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System is poorly defined. The system to address the risk has been implemented but it is poorly conceived.
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System defined but not implemented at all. There is a system defined but has not been implemented at all.
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This assumes that a system is adequately defined in the first place and if it had been implemented properly then it will not be the root cause.
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Conclusion
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Investigation concluded.
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Investigation conducted by:
