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Analyze the causes of an accident with a root cause analysis template

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How to use this form: After an accident, analyze how this accident was caused and how it could have been prevented. Then come up with an action plan of steps to take to prevent such accidents in the future. This form is filled out by the manager, NOT with NOT BY the injured guest or employee. This form may contain information relating to guest or employee health or other private concerns and must be used in a manner that protects their privacy, if at all possble.
Name of person injured:
Date of accident
Accident Causes (Check all that apply)
Physical causes (Select all that apply)
Hazard (select all that apply)
Unsafe behaviors
In a hurry (Please select all that apply)
Other (describe):
Can you think of anything else that might have contributed to causing this injury? List all other possible contributing factors. (long hours, weather, change in process, etc.) Please dig deep to try to discover the actual root cause. One technique is to ask a series of 'why'' questions to get at the basic root cause.
Please describe all that you have discovered about what occured.
Add signature
Take pictures of anything that would add clarity the the explanation, show a condition that needs to be fixed, etc.
ATTACH: The original report, photos, witness statements, signatures of completion of training, relevant policies, etc. Anything that would help us determine the root cause. SEND to: GM, RM, Lorraine Serva (Safety Committee), Lori Thomas
Recommended Corrective Actions To Prevent Future Injury
Think about all possible corrective actions including but not limited to changing or improving: operations procedures, training, personal protective equipment, policies, cleaning products, communications, etc. For example: “cutting gloves have been purchased for employees using knives, and employees need to be instructed on the use of the gloves, and managers need to enforce use of the gloves.” “checked to see that a ladder of the correct height was available to change lightbulbs and will instruct all FOH employees on use of ladders during pre-shift meetings this week.” “will sign employee up for Back Injury Prevention class, and will instruct all new employees how to safely transport multiple glass racks before they begin their job.” “will call janitor and ask them to use a floor degreaser on a regular basis, will place a mat at the transition point from slate to wood.”
1. Describe first recommendation for corrective action:
Issue Will Be Corrected by
Person responsible for ensuring corrective action is completed:
2. Describe second recommendation for corrective action:
Issue will be corrected by:
Person responsible for ensuring corrective action is completed:
Describe third recommendation for corrective action:
Issue will be corrected by:
Person responsible for ensuring corrective action is completed:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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