Information
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Plant
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Department
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Conducted on
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Prepared by
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Personnel
Root Cause Analysis
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Description of the incident ( one phrase )
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Date and time
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Shift
Manpower
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MOST PROBABLE ROOT CAUSE ( to be defined after completing the 5 why's below )
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CONTRIBUTIVE FACTORS
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BBS factors : * eyes not on task * mind not on task * fatigue * Overconfidence * line of fire * lack of balance
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PPE : training provided efficient training verified
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Communication : - supervisor to employee - employee to supervisor - employee to employee
MATERIAL
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MOST PROBABLE ROOT CAUSE ( to be defined after completing the 5 why's below )
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CONTRIBUTIVE FACTORS
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recent process change
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if chemical : SDS available
MACHINE
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MOST PROBABLE ROOT CAUSE ( to be defined after completing the 5 why's below )
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CONTRIBUTIVE FACTORS
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guarding inadequate machine guarding no guarding
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Tools proper tool was not identified proper tool was not available
METHODOLOGIE
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MOST PROBABLE ROOT CAUSE ( to be defined after completing the 5 why's below )
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CONTRIBUTIVE FACTORS
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work permit
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pre-op inspection
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SOP
WORKPLACE
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MOST PROBABLE ROOT CAUSE ( to be defined after completing the 5 why's below )
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Add drawing
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CONTRIBUTIVE FACTORS
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noise illumination floor walls
Corrective action Plan
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Action:
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Responsible
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Due Date
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Follow up: completed ?
