Events and Causal Factors Chart Project

Events and Conditions

No direct communication to anyone prior to leaving

No one to act on messages

Clean up of floor not done immediately

No “wet floor” signs placed

Leak not repaired for four months

1/2/16 – 5:33 am Mary leaves message for Tom (supervisor)

1/2/16 - 5:53am Bob found lying in pool of water

1/2/16 – 5:53 am Air horn sounds

1/2/16 – 5:34 am Sam notices leak and wet floor in valve dept.

1/2/16 – 5:41 am Sam leaves note for Mary to mop up wet floor

1/2/16 5:41 am

Sam goes home

1/2/16 – 5:33 am Tom leaves message for Mary

Emergency response was good

1/2/16 – 6:00 am Ambulance transports Bob to hospital

Key:

Condition

Event

Accident