Root Cause Description

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

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

Collect Initial Data

Collect Information about management systems.

Collect information regarding Physical Controls.

Collect information regarding behaviours.

Examine worksite.

Identify personnel involved.

Identify equipment involved.

Interview Staff/Witnesses.

Examine documentation.

Examine training records.

Examine Health & Safety inspection reports.

Conduct any required tests.

Notes

Events

Here you need to Depict Events using the five "W's" = (who, what, why, where, when) and identify the following;

Causal Factors

Factual Evidence

Add media if relevant.

Relationships

Develop an Events & Causation chart using recognised technique.

eg - fish bone, fault tree, FMEA etc.

Draw Chart
Get chart

Identify system which failed.

Examine the system for problems.

Management Controls

Policy

Was a Policy in place?

Was the policy adequate?

Planning

Was there a plan in place?

Was the plan implemented?

Was the plan adequate?

Control

Who is responsible for the standard?

Was it in accordance with the standard?

Was the responsibility re-assigned?

Who to?

Competence

Is there a required standard?

Was the standard adequate?

Was the person/person competent?

Why was the person not competent?

Implementation

Was the system specified?

Was the system adequate?

Was the system implemented?

Was the system implemented to the required standard?

Communication

Was the system communicated?

Was the communication adequate?

Was it in line with the standard?

Cooperation

Was a standard specified?

Was it adiquate?

Was there cooperation?

Measuring

Was there a standard for measuring the system?

Was it effective?

Were the measures in line with the standard?

Reviewing

Was there a system for reviewing?

Was the system for reviewing adequate?

Was the system reviewed?

Were any reviews in line with the standard?

Were any reviews in line with the standard?

Root Cause

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.

System is adequate but not correctly implemented. There is a system defined, but this is not what was implemented.

System is poorly defined. The system to address the risk has been implemented but it is poorly conceived.

System defined but not implemented at all. There is a system defined but has not been implemented at all.

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.

Conclusion

Investigation concluded.
Investigation conducted by:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.