Incident Investigation – Case Study
nasarb
guide_for_identifying_causal_factors.docAnalysis
Guide for Identifying Causal Factors & Corrective Actions Incident No.:
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1. EQUIPMENT |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.0 Was a hazardous condition(s) a contributing factor? (If yes, answer the following. If no, got to 2. |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.1 Did any defect(s) in equipment/tools/material contribute to hazardous condition(s)?
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FORMCHECKBOX Review procedures for inspecting, reporting, maintaining, repairing, replacing, or recalling defective equipment/tools/ material used. |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
1.2 Was the hazardous condition(s) recognized? A. Was the hazardous condition(s) reported? B. Was employee(s) informed of the hazardous condi-tion and the job procedures for dealing with it as an interim measure? |
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FORMCHECKBOX Perform job safety analysis. FORMCHECKBOX Improve employee ability to recognize existing or potential hazardous conditions. FORMCHECKBOX Provide test equipment, as required, to detect hazard. FORMCHECKBOX Review any change or modification of equipment/ tool/material. FORMCHECKBOX Train employees in reporting procedures. FORMCHECKBOX Stress individual acceptance of responsibility. FORMCHECKBOX Review job procedures for hazard avoidance. FORMCHECKBOX Review supervisory responsibility. FORMCHECKBOX Improve supervisor/ employee communications. FORMCHECKBOX Take action to remove or minimize the hazard. |
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1. EQUIPMENT |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.3 Was there an equip-ment inspection procedure to detect the hazardous condi-tion(s)? |
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FORMCHECKBOX Develop and adopt procedures (ex. an inspection system) to detect hazardous conditions. FORMCHECKBOX Conduct test. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.4 Did the existing equipment inspection procedure detect the hazardous condition? |
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FORMCHECKBOX Review procedures. FORMCHECKBOX Change frequency or comprehensiveness. FORMCHECKBOX Provide test equipment as required. FORMCHECKBOX Improve employee ability to detect defects and hazardous conditions. FORMCHECKBOX Change job procedures as required. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.5 Was the correct equipment/tool/ material used? |
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FORMCHECKBOX Specify correct equipment/ tool/material in job procedure. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.6 Was the correct equipment/tool/ material readily available? |
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FORMCHECKBOX Provide correct equipment/ tool/material. FORMCHECKBOX Review purchasing specifications and procedures. FORMCHECKBOX Anticipate future requirements. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.7 Did employee know where to obtain equipment/tool/ material required for the job? |
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FORMCHECKBOX Review procedures for storage, access, delivery, or distribution. FORMCHECKBOX Review job procedures for obtaining equipment/ tool/material. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.8 Was substitute equip-ment/tool/material used in place of correct one? |
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FORMCHECKBOX Provide correct equipment/tool/material. FORMCHECKBOX Warn against use of substitutes in job procedures and in job instruction. |
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1. EQUIPMENT |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.9 Did the design of the equipment/tool/ material create operator stress or encourage operator error? |
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FORMCHECKBOX Review human factors engineering principles. FORMCHECKBOX Alter equipment/tool/material to make it more compatible with human capability and limitations. FORMCHECKBOX Review purchasing procedures and specs. FORMCHECKBOX Check out new equipment and job procedures involving new equipment before putting into service. FORMCHECKBOX Encourage employees to report potential hazardous conditions created by equipment design. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.10 Did the general design or quality of the equipment/tool contribute to a hazar-dous condition? |
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FORMCHECKBOX Review criteria in codes, standards, specifications, and regulations. FORMCHECKBOX Establish new criteria as required. |
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FORMCHECKBOX Y FORMCHECKBOX N |
1.11 List other causal factors in “Comment” column. |
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FORMCHECKBOX |
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2. ENVIRONMENT |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.0 Was the location of equipment/materials/employee(s) a contributing factor? (If yes, answer the following. If no, got to 3. |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.1 Did the location/ position of equipment/ material/employee(s) contribute to the hazardous condition?
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FORMCHECKBOX Perform job safety analysis. FORMCHECKBOX Review job procedures. FORMCHECKBOX Change the location, position, or layout of the equipment. FORMCHECKBOX Change position of employee(s). FORMCHECKBOX Provide guard-rails, barricades, barriers, warning lights, signs, or signals. |
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2. ENVIRONMENT |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
2.2 Was the hazardous condition recognized? A. Was the hazardous condition reported? B. Was employee(s) informed of the hazardous condition and the job procedures for dealing with it as an interim measure? |
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FORMCHECKBOX Perform job safety analysis. FORMCHECKBOX Improve employee ability to recognize existing or potential hazardous conditions. FORMCHECKBOX Provide test equipment, as required, to detect hazard. FORMCHECKBOX Review any change or modification of equipment/ tool/material. FORMCHECKBOX Train employees in reporting procedures. FORMCHECKBOX Stress individual acceptance of responsibility. FORMCHECKBOX Review job procedures for hazard avoidance. FORMCHECKBOX Review supervisory responsibility. FORMCHECKBOX Improve supervisor/ employee communications. FORMCHECKBOX Take action to remove or minimize the hazard. |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.3 Was employee(s) supposed to be in the vicinity of the equipment/material? |
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FORMCHECKBOX Review job procedures and instruction. FORMCHECKBOX Provide guard-rails, barricades, barriers, warning lights, signs, or signals. |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.4 Was the hazardous condition created by the location/ position of equipment/ material visible to employee(s)? |
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FORMCHECKBOX Change lighting or layout to increase visibility of equipment. FORMCHECKBOX Provide guardrails, barricades, barriers, warning lights, signs or signals, floor stripes, etc. |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.5 Was there sufficient workspace? |
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FORMCHECKBOX Review workspace requirements and modify as required. |
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2. ENVIRONMENT |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.6 Were environmental conditions a contrib-uting factor (ex. illumination, noise levels, air contami-nants, temperature extremes, ventilation, vibration, radiation)? |
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FORMCHECKBOX Monitor, or periodically check, environmental conditions as required. FORMCHECKBOX Check results against acceptable levels. FORMCHECKBOX Initiate action for those found unacceptable. |
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FORMCHECKBOX Y FORMCHECKBOX N |
2.7 List other causal factors in “Comments” column. |
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FORMCHECKBOX |
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3. PEOPLE |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.0 Was a hazardous condition(s) a contributing factor? (If yes, answer the following. If no, got to 4. |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
3.1 Was there a written or known procedure (rule) for this job? A. Did job procedures anticipate the factors that contributed to the accident? |
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FORMCHECKBOX Perform job safety analysis and develop procedure. FORMCHECKBOX Perform job safety analysis and change job procedure.
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3. PEOPLE |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
B. Did employee(s) know the job procedure? C. Did employee(s) deviate from the know job procedure? |
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FORMCHECKBOX Improve job instruction. FORMCHECKBOX Train employees in correct job procedures. FORMCHECKBOX Determine why. FORMCHECKBOX Encourage all employees to report problems with an established procedure to supervisor. FORMCHECKBOX Review job procedure and modify if necessary. FORMCHECKBOX Counsel or discipline employee. FORMCHECKBOX Provide closer supervision. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.2 Was employee(s) mentally and physically capable of performing the job? |
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FORMCHECKBOX Review employee requirements for the job. FORMCHECKBOX Improve employee selection. FORMCHECKBOX Remove or transfer employees who are temporarily, either mentally or physically, incapable of performing the job. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.3 Were any tasks in the job procedure too difficult to perform (ex. excessive concen-trations or physical demands)? |
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FORMCHECKBOX Change job design and procedures. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.4 Is the job structured to encourage or require deviation from job procedures (ex. incentive, piece-work, work pace)? |
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FORMCHECKBOX Change job design and procedures. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.5 List other causal factors in “Comment” column. |
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FORMCHECKBOX |
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3. PEOPLE |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
3.6 Was lack of personal protective equip-ment or emergency equipment a contrib.-uting factor in the injury? A. Was appropriate personal protective equipment (PPE) specified for the task or job? i. Was appropriate PPE available? ii. Did employee know that wearing specified PPE was required? iii. Did employee know how to use and maintain the PPE? |
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FORMCHECKBOX Review methods to specify PPE requirements (e.g. completing a Hazard Assessment Form). FORMCHECKBOX Provide appropriate PPE. FORMCHECKBOX Review job procedures. FORMCHECKBOX Improve job instruction. FORMCHECKBOX Improve job instruction. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.7 Was the PPE used properly when the injury occurred? |
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FORMCHECKBOX Determine why and take appropriate action. FORMCHECKBOX Implement procedures to monitor and enforce use of PPE. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.8 Was the PPE adequate? |
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FORMCHECKBOX Review PPE requirements. FORMCHECKBOX Check standards, specs, and certification of the PPE. |
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3. PEOPLE |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N |
3.9 Was emergency equipment specified for this job (ex. emergency showers, eyewash fountains)? A. Was emergency equipment readily available? B. Was emergency equipment properly used? C. Did emergency equipment function properly? |
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FORMCHECKBOX Provide emergency equipment as required. FORMCHECKBOX Install emergency equipment at appropriate locations. FORMCHECKBOX Incorporate use of emergency equipment in job procedures. FORMCHECKBOX Establish inspection/monitor-ing system for emergency equipment. Provide for im-mediate repair of defects. |
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FORMCHECKBOX Y FORMCHECKBOX N |
3.10 List other causal factors in “Comments” column. |
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FORMCHECKBOX |
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4. MANAGEMENT |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.0 Was a management system defect a contributing factor? (If yes, answer the following. If no, stop. |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.1 Was there a failure by supervision to detect, anticipate, or report a hazardous condition? |
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FORMCHECKBOX Improve supervisor capability in hazard recognition and reporting procedures. |
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4. MANAGEMENT |
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Causal Factors |
Comment |
Recommended Corrective Action |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.2 Was there a failure by supervision to detect or correct deviations from job procedure? |
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FORMCHECKBOX Review job safety analysis and job procedures. FORMCHECKBOX Increase supervisor monitoring. FORMCHECKBOX Correct deviations. |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.3 Was there a super-visor/employee review of hazards and job procedures for tasks performed infrequently? |
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FORMCHECKBOX Establish a procedure that requires a review of hazards and job procedures (preventative actions) for tasks performed infrequently. |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.4 Was supervisor responsibility and accountability adequately defined and understood? |
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FORMCHECKBOX Define and communicate supervisor responsibility and accountability. FORMCHECKBOX Test for understandability and acceptance. |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? |
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FORMCHECKBOX Train supervisors in accident prevention fundamentals. |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.6 Was there a failure to initiate corrective action for a known hazardous condition that contributed to this accident? |
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FORMCHECKBOX Review management safety policies and level of risk acceptance. FORMCHECKBOX Establish priorities based on potential severity and probability of recurrence. FORMCHECKBOX Review procedure and responsibility to initiate and carry out corrective actions. FORMCHECKBOX Monitor progress. |
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FORMCHECKBOX Y FORMCHECKBOX N |
4.7 List other causal factors in “Comment” column. |
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FORMCHECKBOX |
