Root-Cause Analysis

• Location
  Address

• RCA Team Leader

• Conducted on

  Date

Root-Cause Analysis

Issue Details

• Date issue reported

  Date

• Brief description of the issue

• Rate the impact of incident

  Low

  Medium

  High

• Was there damage to property?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Was the associate sent out for post accident testing?

  Yes

  No

  N/A

• Why?

• Did the associate seek medical treatment beyond first aid?

  Yes

  No

  N/A

• Where, and why?

• Was video saved of this incident?

  Yes

  No

  N/A

• Why?

• Where photo's taken of the incident scene?

  Yes

  No

  N/A

• why?

Possible Root Cause

• List potential reasons why the issue happened

CAUSE

• Brief description of a cause

• Rate probability as the root cause

  High

  Medium

  Low

• What is the root cause of the issue?

• Categorize the root cause of the issue

  Select Equipment Malfunction Process Error Distraction Environmental Factors Lack of communication Error Trap Training error Failure to follow policy Other Failure to Stop

  • Equipment Malfunction
  • Process Error
  • Distraction
  • Environmental Factors
  • Lack of communication
  • Error Trap
  • Training error
  • Failure to follow policy
  • Other
  • Failure to Stop

• Please specify

Prevention Strategy

• Solution to be implemented

• Estimated cost

• Are there special considerations?

  Yes

  No

• Please specify

• Are there incidental findings to be reviewed for corrective action?

  Yes

  No

• Please specify

Completion

• Full Name and Signature of RCA Team Leader

  Sign

• List RCA Team Members

MEMBER

• Full Name and Signature

  Sign