Five Why Work Sheet

FIVE WHYs Work Sheet
Business Unit Location Facility Name

Incident Number

Incident date Type of Process: Type of Equipment:

RCA Team: Sponsor Leader : Facilitator : Member :
Incident Brief Description:

FIVE WHYs
1. Why did the above happen? Verification

2. Why did 1 happen?







1 Page 1 of 5
Information Sensitivity: Company Confidential Uncontrolled when printed.
Printed 30 November 2019.
Main Root Cause Category Subset Causal Factor
Assessment, Inspections or Assessment, inspection or audit was not conducted

Audits Assessment, inspection or audit failed to uncover inadequacies in procedures or programs
Results of assessment, inspection or audit were not acted on
Communications Inadequate verbal communication
Inadequate written communication
Inadequate shift turnover communication
Inadequate signalling
Inadequate signage
Contractor Health, Environment N/A
and Safety Management
Design Design standards not utilized
Design standards inadequate
Design standards did not exist
Design did not anticipate the conditions
Design Review failed to uncover inadequacies in design
Design did not consider human factors
Emergency Response N/A
Human Performance Mistake or mental slip
Wilful deviation
Mental overload
Incident and Near Miss N/A
Investigation
Inspection/Quality Control Inspection inadequate
Inspection not conducted
Results of inspection not acted on
Leadership Accountability Management expectations inadequately documented, communicated or enforced
Deviation is accepted
Inadequate resource allocation
Management of Change Management of Change not utilized
Management of Change inadequate for design change
Management of Change inadequate for organizational change
Natural Phenomenon Weather/Wildfire
Insect, reptiles or other animal
Pre-Startup Safety Reviews Pre-Startup Review was not conducted
Pre-Startup Safety Review failed to uncover inadequacies in procedures and/or equipment
Results of Pre-Startup Safety Review were not acted on
Preventive Maintenance/Repeat Inadequate inspection or PM plan
Failure Inspection or maintenance not conducted as required
Inadequate procedures or execution
Incorrect or deficient material installed
Requires additional investigation
Inadequate planning or execution
2 Page 2 of 5
Risk Management / JSA No Risk Assessment

Hazard not recognized
Potential consequences not understood
Controls or preventive systems inadequate
Procedures and Safe Work HES Procedures or Safe Work Practices did not exist
Practices HES Procedures or Safe Work Practices not available
HES Procedures or Safe Work Practices inadequate
HES Procedures or Safe Work Practices not utilized
HES Procedures or Safe Work Practices difficult to use
Operations Procedures did not exist
Operations Procedures not available
Operations Procedures inadequate
Operations Procedures not utilized
Operations Procedures difficult to use
Maintenance Procedures did not exist
maintenance Procedures not available
Maintenance Procedures inadequate
Maintenance Procedures not utilized
Maintenance Procedures difficult to use
Supervision/Work Direction Inadequate selection of worker(s)
Inadequate work oversight or enforcement of work standards
Inadequate work direction or unclear expectations
Training/Competency Not training exists
Training exists but inadequate
Training exists but individual was not trained
Trained but lack of competency/fluency
Root cause category Description of root cause

Protective System Description of root cause

Protective Systems Did Not Work [Insert Protective System Name]
Protective Systems that Worked [Insert Protective System Name]
3 Page 3 of 5
Protective Systems that Would’ve [Insert Protective System Name]

Worked but Do Not Exist
4 Page 4 of 5
Tenets Broken
Operated within design or environmental limits? Maintained integrity of dedicated systems?
Operated in a safe and controlled condition? Complied with all applicable rules and regulations?
Ensure that safety devices where in place and Addressed abnormal conditions?
functioning?
Followed safe work practices and procedures? Followed written procedures for high risk or unusual situations?
Met or exceeded customer’s requirements? Involve the right people in decision that affect procedures and
equipment?
ACTION ITEMS AND TIMEFRAMES MUST BE AGREED WITH ACTIONEE PRIOR TO

COMPLETION OF THE REPORT
Action Items: (complete here or on the investigation report)

Action description:
Target completion date: Start date:

Assigned by: Assigned to:
Responsible department: Responsible location:
Action Description:
Target completion date: Start date:

Assigned by: Assigned to:
Responsible department: Responsible location:
5 Page 5 of 5

Five Why Work Sheet

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Five Why Work Sheet

Caricato da

Copyright:

Formati disponibili

FIVE WHYs Work Sheet

Business Unit Location Facility Name

Incident Brief Description:

Main Root Cause Category Subset Causal Factor

Assessment, Inspections or Assessment, inspection or audit was not conducted

Risk Management / JSA No Risk Assessment

Root cause category Description of root cause

Protective System Description of root cause

Protective Systems that Worked [Insert Protective System Name]

Protective Systems that Would’ve [Insert Protective System Name]

ACTION ITEMS AND TIMEFRAMES MUST BE AGREED WITH ACTIONEE PRIOR TO

Action Items: (complete here or on the investigation report)

Target completion date: Start date:

Target completion date: Start date:

Potrebbero piacerti anche