Root Cause Analysis Form Supervisor’s investigation to injuries and preventable occurrences "*" indicates required fields Region*Select your locationCorpus Christi, TXMidland, TXKilgore, TXLafayette, LAGreeley, COWashington, PACheyenne, WYCasper, WYPersonal Information1. Employee Name:* First Last 2. Hire Date* MM slash DD slash YYYY 3. Employee Number 4. Job Title at the time of the incident and how long in this position? 4a. Date of Incident MM slash DD slash YYYY 5. Work Schedule 24 Hr Call 7/7 5/2 Other 6. Occurrence/Injury was on? Reg. Time Over Time 7. How many consecutive days has employee worked?8a. How many continuous hours worked on employees’ day of incident? (1, 5, 8, 12, etc.) 8b. When the injury / incident occurred, what stage was the job in? Preparation Beginning Middle End 9. TRK LOCATION 10. DEPARTMENT 11. WORK START DATE MM slash DD slash YYYY 11b. WORK START TIME Hours : Minutes AM PM AM/PM 12. DATE OF INCIDENT MM slash DD slash YYYY 12b. TIME OF INCIDENT Hours : Minutes AM PM AM/PM 13. POSITION: At Time Of Incident 14. CUSTOMER 15. RIG#: LEASE & WELL#: 16. INJURY / ACCIDENT LOCATION 17. DATE REPORTED MM slash DD slash YYYY 18. REPORTED TO 19. OTHER EMPLOYEES INVOLVED (WITNESSES) 20. How was the employee qualified to work in the position mentioned above? (Documented training, on-the-job training, etc.) 21. Describe important events leading up to this incident (sequence of events)22. What change, or changes took place AFTER the last successful task? (i.e., pipe ran, weld, tools handled, rolled pipe)23. Describe the actual incident or accident in detail24a. Type of Injury Mechanism Shop Job Job: Land Based Location Water Based Location Water Based Location: Inland Shelf Deepwater Type of vessel incident occurred on? 24b. Type of Injury Mechanism Struck By Struck Against Penetrated Sharp object Lifting Slip Rubbed against Caught In\Under\Between Electrical Current Extreme Temperature Chemical Exposure Fall From Elevation Fall From Same Level Bodily Reaction Other 25. Experience In This Type Of Work Under One Year? One to Three Years Three to Five Years Five to Six Years Six To Ten Years Over Ten Years How many months?Please enter a number from 0 to 12.26. Nature of Injury Abrasion Amputation Bruise / Contusion Foreign Body in Eye Electric Shock Burn Concussion Incision / Cut Fracture Internal Hearing Loss Heat Stress Skin Condition Undetermined Medical Welding Flash Infectious Disease Respiratory Penetrated Poisoned Teeth Damage Whiplash Multiple Injuries Insect Bites / Stings Repetitive Strain Sprain (Joints) Strain (Muscles) Other 27. Source of Injury Animal / Insect Chemical Climatic Foreign Matter Terrain / Floor Personnel Lifts/Elevators Body Reaction Machinery Materials Tools Other 28. Part of Body Injured Head/Face Hand Tailbone/Butt Ear Finger(s) Leg Eye Back Knee Neck Chest Ankle Shoulder Lungs Foot Arm Abdomen Multiple Parts Elbow Hip None Wrist Groin Undetermined Medical 29. Human Cause(s) Failure to take action Incorrect action, operation, movement, handling Non-compliance with policy/procedure No human cause Other 30. Workplace Cause(s) Lack of Proper Poorly Maintained Defective/Poorly Constructed Safety Devices Personal Protective Equipment (PPE) Facilities No Workplace Cause Other 31. Work Being Performed at Time of Incident / Accident Maintenance/Repair Rig Down of Equip. Equipment Operation Office Duties Materials Handling Casing Operations Usage of Hand Tools Travel Equipment Handling Laydown Operations Loading/Offloading Equip. Rig Up of Equipment Welding / Fabrication Grinding Operations Other 32. Other32a. File UploadTake Pictures - Pictures will communicate to all involved a better understanding of the actual event(s) i.e., rig, tongs, footwear, hardhat, safety glasses, bails, pipe, vehicles, facility, etc.Max. file size: 2 MB.33. Was Safety Equipment Provided? If “Yes” mark the appropriate box(s). Glasses or Goggles Footwear Machine Guard Respirator or Mask Impact Gloves Seat Belt Hearing Protection Lock-Out Tag-Out Hard Hat FR Coverall; H2S - Single Stage Gas Monitor Other If Other (please explain) 34. Was proper safety equipment worn? Yes No If NO, please explain: 35. At-Risk Behaviors Working on moving equipment without a guard Using hands instead of equipment Working at a speed which may have contributed to occurrence Apparent unsafe position or posture Equipment / Tool apparently used incorrectly Poor housekeeping / Improper storage No known At-Risk Behavior Other If Other (please specify) 36. Relative to the occurrence (i.e. running casing, electrical repair, lifting) is the employee(s) currently trained? Yes No Is it properly documented? Yes No Please attach any supporting documentation.Max. file size: 2 MB.37. Was a JSA, Pre-Job Checklist, Safety Meeting or any other pertinent information performed before or during the job? Yes No Is it properly documented? Yes No Please attach any supporting documentation.Max. file size: 2 MB.Flow Chart – Cause & Effect “WHY” ModelUse as many branches as needed to identify contributing causes. Framework, you may not need all branches provided or you may need more.Effect Incident / InjuryEnter the result of the injury / incident. Ex. Finger tips cut off. Direct CauseEnter the direct or immediate cause of injury / incident. Ex. Fingers caught between the tool & the wire cable. Contributing Causes (1)Give at least 3 reasons WHY the direct cause occurred.Reason 1Reason 2Reason 3 Add RemoveContributing Causes (2)Give at least 1 reason WHY each contributing cause (1) occurred. Add RemoveRoot Cause(s)Give at least 1 reason WHY each contributing cause (2) occurred. Add Remove37a. Work through the following list of likely sub-causes to discover other possible factors for this occurrence and check whether or not it was a factor:Contributing Causes: SS - (SAFESTART) Likely Sub-causes1-RushingFactor? Yes No 2-FrustrationFactor? Yes No 3-FatigueFactor? Yes No 4-ComplacencyFactor? Yes No 5-Eyes not on TaskFactor? Yes No 6-Mind not on TaskFactor? Yes No 7-Line-of-FireFactor? Yes No 8-Balance / Traction / GripFactor? Yes No Contributing Cause: A - PROCEDURAL/POLICY Likely Sub-causes1-None developedFactor? Yes No 2-Developed - not followedFactor? Yes No 3-Developed - not trainedFactor? Yes No 4-Developed - not understoodFactor? Yes No 5-Developed - not accurateFactor? Yes No 6-Developed - unable to followFactor? Yes No 7-Developed - not monitoredFactor? Yes No 8-Lack of accountabilityFactor? Yes No 9-Other (specify)Factor? Yes No Other Contributing Cause: B - FACILITIES/TOOLS Likely Sub-causes1-Lack of additional equipmentFactor? Yes No 2-Poor designFactor? Yes No 3-Heat stressFactor? Yes No 4-Working long hoursFactor? Yes No 5-Cold temperaturesFactor? Yes No 6-Exertion beyond human limitsFactor? Yes No 7-Weather relatedFactor? Yes No 8-Tool not availableFactor? Yes No 9-Lack of maintenanceFactor? Yes No 10-Other (specify)Factor? Yes No Other Contributing Cause: C - BEING IN A HURRY / PRESSURE Likely Sub-causes1-Verbally implied needFactor? Yes No 2-Employee-perceived needFactor? Yes No 3-DistractedFactor? Yes No 4-Due to external factorsFactor? Yes No 5-Workload too heavyFactor? Yes No 6-Facilities inducedFactor? Yes No 7-Lack of teamworkFactor? Yes No Contributing Cause: D – TRAINING / KNOWLEDGE Likely Sub-causes1-Insufficient trainingFactor? Yes No 2-Lack of retention after trainingFactor? Yes No 3-Circumstances not addressed in trainingFactor? Yes No 4-Poor job selection/placementFactor? Yes No 5-Tool used incorrectlyFactor? Yes No 6-Normal way of completing taskFactor? Yes No 7-Other (specify)Factor? Yes No Other Contributing Cause: E – COMMUNICATION / TEAMWORK Likely Sub-causes1-No planningFactor? Yes No 2-Lack of responsibilityFactor? Yes No 3-Breakdown in communication between workersFactor? Yes No 4-Breakdown in commun. between work teamsFactor? Yes No 5-Breakdown in communication between worker and supervisorFactor? Yes No 6-Confusion after communicationFactor? Yes No 7-Lack of TeamworkFactor? Yes No 8-Working AloneFactor? Yes No 9-Other (specify)Factor? Yes No Other Contributing Cause: F - HAZARD Likely Sub-causes1-Created by manFactor? Yes No 2-Created by external factorsFactor? Yes No 3-Conditions changed w/out proper commun.Factor? Yes No 4-Documented but not repairedFactor? Yes No 5-Identified but acceptedFactor? Yes No 6-Repaired but deficient repairFactor? Yes No 7-UnidentifiedFactor? Yes No 8-Unaware of HazardFactor? Yes No 9-Other (specify)Factor? Yes No Other 38. What hazardous conditions contributed to the cause of this incident or accident?39. List the codes (i.e. C-4, etc.) from the sub-causes in step 37a, state why they occurred, and detail an action plan for each identified cause.Sub-causesWhy did this occur? (Root Cause)Action plan to prevent re-occurrence. Every action plan should be measurableResponsible PartyTarget DateStatus (Open, Closed, In-Progress) Add Remove40. List detail(s), if any, of other causes and / or corrective actions to prevent a similar type of occurrence:41. Further training needed? Yes No If Yes, explain: 42. Employee’s Signature:* Employee’s Name: 43. Manager’s/Department Head’s Signature: Manager’s Name: 44. RCA conducted by:*(All participants) Today’s Date:* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
