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Incident Reporting - Root Cause Analysis Report

Author: Novade Solutions

Simplify incident reporting and root cause analysis, providing tools to uncover causes, improve safety measures, and prevent future occurrences

Published on: 11/26/2024

Incident Reporting - Root Cause Analysis Report

General information

Organization

Report No.

Facility

Report Date

Location

Date of incident

Address

RCA initiated by

RCA Team Members

RCA Member

S/N	Name	Role
-	-	-

Edit Table

Incident Documentation

Was an incident report completed?

If RCA was initiated from an Incident Report, Dangerous Situation Report, or other document, not the document identification number.

Remarks

Describe the incident. Include all pertinent information including injuries, damages, and causes if known.

Description

Leading Event Determination

Describe normal leading sequence to a non-incident. How were things supposed to occur normally?

Remarks

Did a deviation from normal leading sequence occur? If so, describe in detail.

If yes, describe in detail.

Did a deviation lead to or cause the incident?

If yes, describe in detail.

Is there written documentation of the expected sequence or was a normal operating sequence witnessed to distinguish between a typical and non-typical event?

If yes, cite the reference documentation.

Are there any regulations or requirements that the nominal sequence of events adheres to?

If yes, cite the source of the regulation.

Were there any actions or lack of actions that contributed to the incident?

Describe as required.

Were there any defects, mechanical failures, or other non-human actions or events that contributed to the incident?

Describe as required.

Were there any conditions that contributed to the incident occurence?

Remarks

Were there any conditions that contributed to the incident occurence?

Witnesses and employees present at time of incident

S/N	Name	Witness/Employee?
-	-	-

Edit Table

If staff were present in the area and time of the incident, were they adequately trained to deal with the event?

Remarks

Were there any staffing factors that may have contributed to the incident?

Remarks

Were there adequate procedures in place to respond to the incident?

Remarks

Were there any witness factors that may have contributed to the incident?

Remarks

List any other contributing factors that may have played a role in causing the incident.

Remarks

Root cause identification

Was a root cause or causes determined? List the contributing factors and their probability for causing the incident.

Contributing Factor Description

Probability of Involvement

Corrective Action Identification

Describe the action steps taken already to prevent a recurrence of the incident.

Date implemented

Recommended Preventive Strategy

List the possible actions to take to prevent a recurrence of the incident.

Recommended Action

Action Considerations

Root Cause Analysis Summary

Note any further information required for further investigation, a brief summary of the RCA findings, or other information that needs to be communicated.

Submitted By:

Signature of Submitter

Date & Time

Checked By:

Signature

Date & Time

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Incident Reporting - Root Cause Analysis Report

General information

Organization

Report No.

Facility

Report Date

Location

Date of incident

Address

RCA initiated by

RCA Team Members

RCA Member

S/N	Name	Role
-	-	-

+ Add New Row

Incident Documentation

Was an incident report completed?

If RCA was initiated from an Incident Report, Dangerous Situation Report, or other document, not the document identification number.

Remarks

Describe the incident. Include all pertinent information including injuries, damages, and causes if known.

Description

Leading Event Determination

Describe normal leading sequence to a non-incident. How were things supposed to occur normally?

Remarks

Did a deviation from normal leading sequence occur? If so, describe in detail.

If yes, describe in detail.

Did a deviation lead to or cause the incident?

If yes, describe in detail.

Is there written documentation of the expected sequence or was a normal operating sequence witnessed to distinguish between a typical and non-typical event?

If yes, cite the reference documentation.

Are there any regulations or requirements that the nominal sequence of events adheres to?

If yes, cite the source of the regulation.

Were there any actions or lack of actions that contributed to the incident?

Describe as required.

Were there any defects, mechanical failures, or other non-human actions or events that contributed to the incident?

Describe as required.

Were there any conditions that contributed to the incident occurence?

Remarks

Were there any conditions that contributed to the incident occurence?

Witnesses and employees present at time of incident

S/N	Name	Witness/Employee?
-	-	-

+ Add New Row

If staff were present in the area and time of the incident, were they adequately trained to deal with the event?

Remarks

Were there any staffing factors that may have contributed to the incident?

Remarks

Were there adequate procedures in place to respond to the incident?

Remarks

Were there any witness factors that may have contributed to the incident?

Remarks

List any other contributing factors that may have played a role in causing the incident.

Remarks

Root cause identification

Was a root cause or causes determined? List the contributing factors and their probability for causing the incident.

Contributing Factor Description

Probability of Involvement

Corrective Action Identification

Describe the action steps taken already to prevent a recurrence of the incident.

Date implemented

Recommended Preventive Strategy

List the possible actions to take to prevent a recurrence of the incident.

Recommended Action

Action Considerations

Root Cause Analysis Summary

Note any further information required for further investigation, a brief summary of the RCA findings, or other information that needs to be communicated.

Submitted By:

Signature of Submitter

Date & Time

Checked By:

Signature

Date & Time

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