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)

  • What is the MHE identifying number?

  • Was the MHE checklist completed?

  • Was the associate sent out for post accident testing?

  • Why?

  • Did the associate seek medical treatment beyond first aid?

  • Where, and 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

  • 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

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