PCI ROOT CAUSE AND PREVENTION ANALYSIS

ROOT CAUSE AND PREVENTION ANALYSIS
PCI Location*
Employee Name:

First NameLast Name
1. What task was the employee performing prior to the injury/auto crash?
2. Describe any tools, machinery or equipment that was being used at the time of the injury/auto crash?
3. Was the employee working alone?
If no, who with?
4. How much experience did the person have in performing this task? (Months on the job)
STEP 1
OBTAIN AND REVIEW PHYSICAL, PEOPLE, AND PAPER EVIDENCE PERTINENT TO THE INVESTIGATION.
- Physical: photographs/drawings/equipment manual/etc.
- People: Witness Statements & Interviews/ Employee Report of Incident
- Paper: Policies/Programs/Procedures/Training Records/Maintenance Records/Prior Incident Reports/etc.
STEP 2 ROOT CAUSES

• Use this listing as an aid for identifying the factors that lead to the incident. • Don’t be limited by the categories listed--add items (Other) as needed. Check all that apply.
Not developed or inadequateDeveloped – Not CommunicatedDeveloped – Not UnderstoodDeveloped – Not FollowedLack of Disciplinary PolicyDisciplinary Policy Not Enforced
Other:
Insufficient planning for tasksLack of workers communicationLack of supervisor instructionsWork team breakdownConfusion after communication
Other:
Unidentified or Not LabeledKnown but Not CorrectedKnown but Not ReportedCreated by External FactorsDocumented but Not RepairedCondition Changed Not ConveyedEquipment Repaired DeficientlyPPE Not Adequate or DefectiveOther
Poor facility designPoor/faulty equipment designAwkward workstation designEquipment not guardedEquipment repair deficientLack of preventive maintenanceLack of storageOther
Heavy workloadTight ScheduleLong/Unusual Working HoursFalsely Perceived Need to HurryAssistance UnavailableAssistance InadequateChanges in ProcessOther
Shortcuts takenDefensive driving training not followedSafe work methods not followedTool/equipment used incorrectlyHistory of accidents/incidentsDisregarded/refused to follow procedure(s)Assistance required Not requestedHorseplayOther
Deficient Orientation TrainingDeficient Job-Specific TrainingInsufficient Training for New Process/TaskLack of Supervisor Follow-Up/ReinforcementLack of Supervisor TrainingHazards Overlooked in TrainingOther
Weather, TemperaturePoor HousekeepingPoor LightingPoor VisibilityAir QualityNoiseOther
STEP 3
CAUSE(S)
POLICIES/PROCEDURESCOMMUNICATIONHAZARD(S)TRAININGPOLICIES/PROCEDURESWORK BEHAVIORFACILITIES/EQUIPMENTENVIRONMENT
Notes:
Follow-up & Prevention Activity
Additional Corrective Actions
Driver Signature
Supervisor Signature*
Supervisor Name*

First NameLast Name
SUPERVISOR EMAIL*
example@example.com
Should be Empty:

ROOT CAUSE AND PREVENTION ANALYSIS

STEP 1

STEP 2 ROOT CAUSES

STEP 3

CAUSE(S)