INCIDENT INFORMATION
Incident Date: Incident Time:
Location: Department / Project:
Employee(s) Involved: Supervisor:
Investigator(s): Date Investigation Began:
Event Type: ☐ Injury / Illness ☐ Near Miss ☐ Property Damage ☐ Equipment Failure ☐ Environmental Release ☐ Other:
INCIDENT DESCRIPTION
Describe what happened using factual information. Include the task being performed, equipment/materials involved, and the sequence of events. Avoid assigning blame or drawing conclusions at this stage.
IMMEDIATE RESPONSE AND HAZARD CONTROL
Immediate actions taken:
Hazard(s) controlled / area secured:
Medical or emergency response, if applicable:
INFORMATION AND EVIDENCE REVIEWED
Check applicable items and identify other evidence used during the investigation.
☐ Employee interview(s) ☐ Witness interview(s) ☐ Photographs / video ☐ Equipment inspection
☐ JSA / JHA ☐ Written procedure ☐ Training records ☐ Inspection records ☐ Maintenance records
☐ Permits / SDS / other documents ☐ Site conditions ☐ Other:
IMMEDIATE CAUSE(S)
Identify the unsafe condition, action, equipment failure, or event directly associated with the incident. Do not stop the analysis here.
CONTRIBUTING FACTORS
Identify conditions or circumstances that increased the likelihood or severity of the event.
Consider: ☐ Equipment / tools ☐ Procedures ☐ Training ☐ Supervision ☐ Communication ☐ Work environment ☐ Staffing / workload ☐ Planning / JSA ☐ Maintenance ☐ PPE ☐ Human factors ☐ Other
WHYS ROOT CAUSE ANALYSIS
Begin with the incident or a significant contributing factor and continue asking “Why?” until the underlying system or process failure is identified. More or fewer than five questions may be necessary.
Step Question/Finding
Why 1?
Why 2?
Why 3?
Why 4?
Why 5?
ROOT CAUSE(S)
Identify the underlying system, management, process, equipment, planning, training, supervision, or other failure(s) that allowed the incident to occur. A root cause should point toward a condition that can be corrected.
CORRECTIVE AND PREVENTIVE ACTIONS
Develop actions that address the identified root cause(s). Give priority to eliminating hazards and using engineering or other higher-level controls where feasible.
| Corrective / Preventive Action | Root Cause Addressed | Responsible Person | Due Date | Completed (yes/no) |
CORRECTIVE ACTION VERIFICATION AND EFFECTIVENESS REVIEW
Corrective actions completed and verified?
Were the root cause(s) adequately addressed?
Additional action required?
Effectiveness review date:
LESSONS LEARNED / COMMUNICATION
Identify whether procedures, JSAs, training, inspections, equipment, or other safety programs should be revised and how lessons learned will be communicated.
☐ JSA / JHA revised ☐ Procedure revised ☐ Training conducted ☐ Safety meeting / toolbox talk
☐ Equipment / engineering change ☐ Inspection / maintenance change ☐ Safety program revised ☐ Other
INVESTIGATION REVIEW AND CLOSEOUT
Investigator: Date
Supervisor / Manager: Date
Safety / HSE Review: Date
Note: Root Cause Analysis should focus on identifying and correcting underlying causes rather than assigning blame. Serious incidents may require additional investigation, reporting, regulatory notification, or specialized analysis.