Page 571 - Safety Memo
P. 571
Root Cause Analysis (RCA)
Name of person initiating Root Cause Analysis:
Date and time of incident:
Person(s) involved in incident:
Describe the incident in as much detail as possible (i.e. What task was the injured employee performing prior
to the accident/near miss? Describe any tools, machinery, or equipment that was being used at the time of
the incident. How much experience did the injured person have in performing this task?):
Were there any recent changes to the work area before work started? Please describe the changes.
Were hazards identified in the work area before working? If yes, what were the hazards? If no, why not?
What preventive actions were taken to mitigate the hazards?
What actions will be taken to prevent further incidents of the same nature? Who will do them?
