Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Safety Nets Root Cause Analysis
1.0 Risk Assessment
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A risk assessment was performed specific to the site, activity, and work area and identified the hazards, risks, and controls required to prevent the accident
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A risk assessment was performed specific to the site, activity, and work area but did not identify or incorrectly identified the hazards, risks, and controls required to prevent the accident
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No risk assessment safety net was conducted
2.0 Safe System of Work / Permit to Work / Safety Processes
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A safe system of work and work processes, including permit to work, for high hazard work, were in place and functional
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A safe system of work, including permit to work and processes, for high hazard work, were in place and functional but did not identify or control the cause of the incident
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No safe system of work or permit safety net process in place
3.0 Training and Supervision
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Training and supervision was in place and appropriate for the activity
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Training and supervision was in place but failed due to not specifically training all of the tasks, or not asking trainee to demonstrate the learnings, or not supervising the work after trainee was on task
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No safety net for training or supervision was not performed
4.0 Physical Barriers / Guarding / Interlocks
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Physical barriers, machine guards, locks and interlocks, were in place and functional
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Physical barriers, machine guards, locks and interlocks, were in place but failed or were overridden or compromised
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No safety net physical barriers in place
5.0 Correct Tools & Equipment
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The correct tools including PPE for the specific job were available, in good condition, being used, and were appropriate for the hazards on the specific job
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The correct tools including PPE for the specific job were available, but not in good condition, not being used, or were not appropriate for the hazards on the specific job
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No safety net assesssment for the proper tools, equipment, and PPE was not conducted OR provided for use
6.0 Safety Walks / Observations
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A safety walk/observation program is in place, functional, and being used to observe work behaviors
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A safety walk/observation program is in place but the observations were not being recorded frequently and records were inconsistent
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No safety net safety walks or observation process in place
7.0 Three Checks for Safety
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The 3 Checks fo Safety are understood, applied, and fully integrated into the work process
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The 3 Checks fo Safety are partially understood, applied, and not fully integrated into the work process
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No 3 Checks for Safety net in place
