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Investigation 5 Why Incident Report Card

Investigation 5 Why
Complete all 10 sections on this form

1. Investigation details
Safeguard incident number

Date investigation began

31/01/2014

Investigation lead (name)

Investigation facilitator (name)

Other investigation team members


(if any)

2. Brief description of the incident: (refer to Incident Initial Details form)


Two Heat Treatment Technicians received an electric shock (60V) while setting up pre-weld heating
equipment

3. 5 WHYs
1. Why did the above
happen?
Verification
2. Why did 1 happen?
Verification
3. Why did 2 happen?
Verification
4. Why did 3 happen?
Verification
5. Why did 4 happen?
Verification
6. Why did 5 happen?
Verification
7. Why did 6 happen?
Verification
8. Why did 7 happen?
Verification

Investigation 5 Why Incident Report Card


4. Main root cause category
Assessments or Audits
Assessment or audit failed to uncover
inadequacies
Assessment or audit not conducted
Results of assessment or audit not acted
upon
Communications
Inadequate shift turnover communication
Inadequate signage
Inadequate signalling
Inadequate verbal communication
Inadequate written communication
Contractor Health, Environment, and
Safety Management
Contractor Health, Environment, and Safety
Management

Pre-Startup Safety Reviews


Failed to uncover inadequacies in
procedures and/or equipment
Not conducted
Results were not acted upon
Preventive Maintenance, Inspection,
Testing, or Repair
Inadequate
Inadequate maintenance planning
Not conducted
Program does not exist
Results were not acted upon

Incident and Near Miss Investigation


Incident and Near Miss Investigation

Procedures and Safe Work Practices


HES Procedures or Safe Work Practices not
available
HES Procedures or Safe Work Practices did
not exist
HES Procedures or Safe Work Practices
difficult to use
HES Procedures or Safe Work Practices
inadequate
HES Procedures or Safe Work Practices not
used
Maintenance Procedures not available
Maintenance Procedures not used
Maintenance Procedures did not exist
Maintenance Procedures difficult to use
Maintenance Procedures inadequate
Operations Procedures not available
Operations Procedures not used
Operations Procedures did not exist
Operations Procedures difficult to use
Operations Procedures inadequate

Quality Control or Acceptance Testing


Inadequate
Not conducted
Not required
Results not acted on

Risk Management/JSA
Controls or preventive systems inadequate
Hazard not recognised
No Risk Assessment
Potential consequences not understood

Leadership Accountability
Deviation is accepted
Inadequate resource allocation
Management expectations inadequately
documented, communicated, or enforced

Supervision/Work Direction
Inadequate selection of worker(s)
Inadequate work direction or unclear
expectations
Inadequate work oversight or enforcement
of work standards

Design
Design did not anticipate the conditions
Design did not consider human factors
Design review failed to uncover
inadequacies in design
Design standards did not exist
Design standards inadequate
Design standards not used
Emergency Response
Emergency response
Human Performance
Mental overload
Mistake or mental slip
Wilful deviation

Management of Change
Inadequate for design change
Inadequate for organisational change
Not used
Natural Phenomenon
Insect, reptiles, or other animals
Weather/wildfire

Training/Competency
No training exists
Trained but lack of competency/fluency
Training exists but inadequate
Training exists but individual was not
trained

Investigation 5 Why Incident Report Card


Description of root causes:

5. Tenets broken
Address abnormal situations

Involve the right people in decisions

Comply with all rules and regulations

Maintain integrity of dedicated systems

Ensure safety devices are in place and


functional

Meet or exceed customer requirements


Operate in a safe and controlled condition

Follow safe work practices and procedures

Operate within design and environment limits

Follow written procedures for high-risk/unusual


situations

6. Actions Item (1)


Task title:

Task
description:

Allocate action
to:

Scheduled
date:

Controls
hierarchy

Administrative

Tick to mark this


complete
Responsible
department:
Elimination

Engineering

PPE

Substitution

Action note:

7. Actions Item (2)


Task title:

Task
description:

Allocate action
to:

Scheduled
date:

Controls
hierarchy

Administrative

Tick to mark this


complete
Responsible
department:
Elimination

Engineering

PPE

Substitution

Action note:

8. Actions Item (3)


Task title:

Task
description:

Allocate action
to:

Scheduled
date:

Controls
hierarchy

Administrative

Action note:

Tick to mark this


complete
Responsible
department:
Elimination

Engineering

PPE

Substitution

Investigation 5 Why Incident Report Card


9. Actions Item (4)
Task title:

Task
description:

Allocate action
to:

Scheduled
date:

Controls
hierarchy

Administrative

Tick to mark this


complete
Responsible
department:
Elimination

Engineering

PPE

Substitution

Action note:

10. Investigation close-out


Does the investigation require restricted viewing in SafeGuard? (sensitive incidents only)
No
List of documents to attach to
investigation (if any):

Yes