RCA Form - User Guidance

Begin on
This tool has been designed to assist users in performing Root Cause Analysis Tabfor
(RCA) "1.Incid
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Supporting documentation for
This Tool includes guidance on how to complete the 8 Steps as well as provide guidance on t
Analysis process using the Cause & Effect (Fishbone) and 5 Why methods.

Once Tab 1 has been completed, potential cau

This tool provides users a questioning guide to help collect relavent information to determine 5-why
appropriate Causal Factors (based on information known to date by non-experts) that need to be investigat
the 5 Why method.

Continue to Tab "2. 5-Why and action plan". This tab

HSE standard documentation, commu
This tool will also assist users in identifying the required fields for entry into Enablon (i.e. Direc
Cause fields etc.)

Supporting document
2a - Directions for us
2b - 5-why root cau
Overall purpose: This process is meant to help non-experts identify the most likely causes to an
to prevent a reoccurence. Statements and findings about causes and actions to take are prelim
final draft) and based on available information. Regardless of how written, no statement is to
an admission by the company. This processTo print: aHighlight/click
reflects the to
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dance HOW TO USE:

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and action plan". This tab contains the 5-why dynamic tool, as well as action plan,
rd documentation, communication and final closure documentation.
ntry into Enablon (i.e. Direct Cause & Root

Supporting documentation for Tab 2 included:

2a - Directions for using 5-why dynamic tool
2b - 5-why root cause potential outcomes
the most likely causes to an incident to try
nd actions to take are preliminary (even in
written, no statement is to be construed as
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faith effort "green" tabs
improve #1 and #2. The print range should be pre-set.
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Print as normal.
,
8 Step Process 8 Step Process
1- Select the Team 1
2- Incident (problem) description 2
3- Develop Interim Containment Plan based 3
on Direct Energy; Implement and verify
Immediate Actions
4a. Determine Causal (Contributing) Factors
Causal Factor / Fishbone
4.b. Identify and Verify Root Causes
“5 Why” follows (based on list above)
5. Choose and Verify Corrective Actions
6. Take Preventive Measures (based on Root
Cause) System (Control) Improvements
7. Lessons Learned
8. Verify Closure. Thank the Team
5
6
7
8
8 Step Process
1
2
3

5
6
7
8
 4b 5 Why - transcribe root causes found into 5 why analyses (5 why format attached into "5 Whys" tab)
identified Causal Factor until you get to
RCA - 5 Why (Simply ask 'Why' to the

Root Cause

5 Choose and Verify Corrective Actions for Causal / Contributing Factors (i.e. Replace broken ladder, train employee etc.)

Nr. Describe Corrective Action Here Responsibility End Date

2
Corrective Actions - Direct
Causes & Causal Factors

6 Nr. Take Preventive Measures to Address Root Causes Identified from 5 Why Responsibility End Date Status

1
2
Take Preventive Measures

3
for Root Causes

4
5
6

9 Verify All Closure Remained Closed 30 days

10 Verify All Closure Remained Closed 90 days

7 Communication - Sharing of Lessons Learned - Do any of the corrective/Preventive actions listed above apply to other processes or systems?

If Yes, Describe Actions to Ensure Proper Sharing/Communication Responsibility End Date

Communication

2
If No, provide justification for non-necessity:

8 Closure Verification - Once the Corrective Actions have been verified, Close and Congratulate the Team:
Verifica

Final Closure Date: (date all action items above are closed) Closed By:
Closur

tion
e
tc.)

Status

- Step 5 is the section to enter in Corrective actions to

those Direct Causes and Casual Factors identified in
sections 2 through 4a.
- Be sure to clearly describe the corrective action to be
taken and that responsible parties are assigned with
end dates established.

- Step 6 of the process is to implement and validate

the corrective actions. In this section of the template,
simply describe the process/method to ensure that
these actions are to be managed and verified
complete & effective.

Status

- Step 7 is for preventive measures to address the

Root Causes and SOP Weaknesses / Opportunities
identified in section 4b. Use this section to input
these preventive actions.
- Be sure to clearly describe the preventive action
to be taken and that responsible parties are
assigned with end dates established.

es or systems?

End Date

- Step 8 is for communication lessons learned,

verifying all assigned actions are complete,
closing the Analysis and thanking the team.
- First, determine if sharing of lessons learned as
a result of the incident are required within your
operation or Mondelez globally etc.
- Next, validate that all assigned actions have
been completed.
- Lastly, thank the team for all their work and
close the Analysis
 Líder del equipo: Mario Garcia

RCA - Hoja de Solución de Problema Miembros del equipo:

Kevin Jair Ortiz // Gerson Garza Villa

Incidente / Problema:
1 Golpe en antebrazo y hombro derecho

Diagrama / Foto
Obra La Proeza

Área Sotano 3

Área especifica Rampa, Sotano 3

Hechos

Fecha del incidente 24 de Junio 2020

Empleado lesionado Kevin Jair Ortiz, 18 años, Union Libre,1 hijo

Recreación de la ecena, acarreo de Tropíezo con materia regado en Alineador de cimbra con el que se Herida ocasionada.
casetones. rampa. golpeo el pomulo.

YE
¿Accidentes previos? ✘ NO
si S no
En caso afirmativo, describa:

Selecciona la causa directa de la lista Caída en el mismo nivel (resbalar/tropezar/caer, volcarse)

2 de la derecha

Preguntas

Qué pasó exactamente Tropezo con material, lesion el pomulo derecho ocasionado por alineador de cimbra.

Dónde ocurrió Rampa de sotano 3

Descripción del incidente

Quién estuvo involucrado Kevin Jair Ortiz

Cómo pasó Tropieza al momento de estar acarreando casetones

Cuándo ocurrió Miercoles 24 de junio del 2020 aproximadamente a las 16:32

sistema(s) fue(ron)
Cuál NA
impactado(s)
Fecha
3 Nr. Medidas de contención provisionales (Inmediatas/Acciones de Emergencia) Responsable
compromiso
Estatus

1 • Se acude al sitio para validar la gravedad de la herida, solo presenta un rasguño. Verificado
Contención

2 • Se realiza investigación del evento Cynthia Villegas (TSI) 6/26/20 Completo

Describa la manera correcta de hacer la actividad (SOP,

4a Describa el principio de funcionamiento del equipo DPS, Procedimiento Operativo, etc)
y la manera correcta de realizar la actividad
Defina el principio de funcionamiento

NA No se cuenta con procedimiento operativo.

Maquina Material Medio ambiente

4b
Falta de orden y limpieza en rampas de sotanos.
No se cuenta con lugar especifico de acopio de materiales.

EFECTO
Causa & Efecto (Diagrama de pescado)

Golpe en pomulo derecho

Falta de seguimiento areas de contrucción conluidas, para que estas *Kevin Ortiz, se encontraba en su penultima hora de jornada
sean entregadas limpias y ordenadas. laboral.

Método Liderazgo / Administración Mano de obra

RCA HSE 7-5A, Rev. 1

June 22, 2016
 Análisis 5 Porqué - Agregue el número de factores causales necesarios y "por qués".
4c
La causa raíz debe identificarse al final (ver renglón ejemplo) consultar pestaña "2b" para los SOP.
Análisis 5 por qué

5 Elije y verifica las acciones correctivas para las causas directas y los factores causales

Jerarquía de Fecha ¿Efec

Nr. Describa las acciones correctivas aquí Tipo de acción Responsable Estatus
Acciones recomendadas para las causas directas (Correctivas)

control compromiso tiva?

Asignacion de recursos por parte de contratistas invoucrados para orden y limpieza en
1
rampas de sotanos. Correctiva Eliminar
Controles En proceso No
Aplicación de sanciones a contratistas por falta de cumplimiento a areas de oportunidad que administrativo
3
ponen en riesgo la integridad fisica de los trabajadores. Preventiva s En proceso No
4
No

5
y causa raíz (Preventivas)

No
6
No
7
No
8
No
9
No
10
No
11
No

12
No
13
No
14
No
15
No
16
No
Enlista las políticas o estándares de HSE relevantes basado en las acciones recomendadas para implementar
6
políticas HSE
Estándares y

Comunicación - Compartir las lecciones aprendidas - ¿Alguna de las acciones correctivas/preventivas enlistadas aplica a otro proceso o sistema? Si
7 Nr. En caso afirmativo, describa las acciones para asegurar la apropiada comunicación/réplica Responsable
Fecha
Estatus
¿Efec
compromiso tiva?

1
Comunicación

No
2
No
3
Yes
En caso negativo, proporcione la justificación de por qué no es necesario: SEN aprobado con el líder de área antes de enviarse

8 Verificación y cierre - Una vez que las acciones correctivas fueron verificadas y cerradas de manera efectiva, se cierra el análisis:
Verificación y

Fecha final de cierre: (fecha en la que todas las acciones mecionadas fueron cerradas) Validado por:
cierre

RCA Rev. 1, 23 May 2016

 Team Leader:

RCA Problem Solving Sheet Team Members:

1 Problem:

Sketch / Photo
Work

Area / Workspace
Facts / Team Building

Product /
component
C
No of Defects doc
memb
"Facts"
Date Discovered

Discovered by

Previous Incident? Yes No

If yes, describe:
From the
Select the Direct Cause from appropria
2 Drop-Down to the Right Falls on same level (Slip/trip/fall, tip0over) manda
Question Description
Incident Description / Detail

What exactly happened?

Where did it happen?

Who was involved? To compl

the rele
provid
How did it happen?

When did it happen?

Why did it happen?

3 Nr. Immediate Countermeasure Plan (Immediate/Emergency Actions) Responsibility Due Date Status Step
an in
1 hazar
Contain

can
2
3

4a Man Machine Material

Contributring Factors (Fishbone Analysis)

Problem:
For st
Fac
reco
Question
each

Upon
Causa
Diagram
have fact
have m

Method Management Environment

 Complete section 1 by selecting and
documenting the team leader and team
members for this Analysis. Next provide the
"Facts" of the incident known at the time of the
incident

From the provided drop-down - Select the most

appropriate Direct Cause of the incident - this is a
mandatory field required to be entered into
Enablon

To complete the remainder of section 2, collect all

the relevant facts and answer the questions to
provide additional detail about the incident.

Status Step 3 requires that you establish and document

an interim containment plan to ensure that the
hazard/exposure is controlled and that no others
can be affected. Be sure to assign responsible
parties and due dates, as necessary.

em:
For step 4a, you need to determine the related Causal
Factors that allowed this incident to happen. It is
recommended that users refer to the Causal Factor
Questions tab within this tool and answer the questions for
each of the 6 Causal Categories to help identify the
applicable Causal Factors.

Upon completion of the questions, input the applicable

Causal Factors into the boxes available in the Fishbone
Diagram to the left. In each case not all 6 categories will
have factors needing to be entered. In some cases, you may
have multiple factors in a single category. Populate and
manipulate the boxes as necessary
Facts / Team Buildin
1 Sketch / Photo 4b
Previous Incident? Yes No 5
If yes, describe: not applicable

Select the Direct Cause from

2 Drop-Down to the Right Other
Question Description

Corrective Actions - Direct

Causes & Causal Factors
What exactly happened? cocoa drying machine caught fire and gutted the factory section
Incident Description / Detail

Where did it happen? Cocoa drying processing area

Who was involved? The machine operator- Robert, David, Iyosiola.

During cocoa drying operation, the drying burner backfired and resulted into fire gutting the machine cubicle and some other
How did it happen
elctronic c/electrical components on the machine, along side the factory roofing.

When did it happen? During the Morning shift, normal production

Why did it happen? Faulty automatic firing unit programmer that regulates combustion.

3 Nr. Interim Containment Plan (Immediate/Emergency Actions) Responsibility Due Date Status 6
The fire was put off using fire hydrant line, CO2 cylinder directly connected to the combustion chamber
All/ fire marshalls Immediate
1 and Co2 extinguisher hung. Done

Roll call was taken to identify missing colleague and everyone was present Tolu Immediate
2 Done
Contain

Take Preventive Measures

Incident scene was preserved. Plant team
3 Done

for Root Causes

4a Man Machine Material

Inability to activate Faulty programmer of the

extinguisher swiftly. burner Cocoa beans has some dust Problem:
No chimney as vent for residual , loaded into the
Awarenes and skill of
exhessive heat. machine bin
Cocoa drying
operating procedure. machine
Cause & Effect (Fishbone)

.
caught fire
and gutted
work area and 7
machine
non availability of a quick Basic information of m/c
release valve on not available. Work area is dusty as a

Communication
extinguisher bottle. Machine already being result of dust generated
Not closing the fuel line of considered for replacement from the raw cocoa
the burner quickly when fire of the machine considering beans
was detected risk assessment outcome.

Method Management Environment

8
Verifica
Closur

tion
e
 4b
5 Choose and Verify Corrective Actions for Direct Causes & Causal Factors (i.e. Replace broken ladder, train employee etc.)

Nr. Describe Corrective Action Here Responsibility End Date Status

Machine: Burnt machine to be phased out and replaced with safer design. Robert Ogirri, Nasir
1
Machine brochure to be shared with Ronald/Dawie before purchase. malik, Bolaji
Akinbinu Kunle,
2 Materials: Cocoa beans to be precleaned before supply to Ondo plant
George Olagunju.
Corrective Actions - Direct
Causes & Causal Factors

Bolaji/Tolu,
3 Man: Operator to be trained on emergency preparedness and SOP adherence
Olagunju

Management: Basic information like p&ID drawings, manuals, machine details to be requested prior to Robert, Nasir,
5
procurrement of machine /equipment. Adesalu

6
Nr. Take Preventive Measures to Address Root Causes Identified from 5 Why Responsibility End Date Status

Machine: Ensure that all recommendation for safer design are included in new machine and all Robert Ogirri, Nasir
1
installations/commition and knowledge transfer are done as per supplied specification malik, Bolaji

Robert Ogirri, Nasir

Take Preventive Measures

2 Machine/Method: Improve program evaluation/ Inspection and Audit throughout operations

malik, Bolaji
for Root Causes

Man/Machine: Improve Hazard Identification and Risk Assessment by providing training for relevant
3 Bolaji
employees

10

7 Communication - Sharing of Lessons Learned - Do any of the corrective/Preventive actions listed above apply to other processes or systems?

If Yes, Describe Actions to Ensure Proper Sharing/Communication Responsibility End Date

Communication

If No, provide justification for non-necessity: SEN to be agreed with Area Lead prior to sending.

8 Closure Verification - Once the Corrective Actions have been verified as closed and effective, Close the Analysis and Congratulate the Team:
Verifica

Final Closure Date: (date all action items above are closed) Verified By:
Closur

tion
e
 Team Leader: Joe Supervisor 4b
RCA - Problem Solving Sheet Team Members: Injured Employee, Building Manager

RCA - 5 Why (Simply ask 'Why' to the identified

Causal Factor until you get to Root Cause
1 Problem: Employee injured lower back lifting a heavy package.

Sketch / Photo
Work Loading Pallets for Shipping

Area / Workspace Shipping & Receiving Department

Facts / Team Building

Product /
NA
component

No of Defects 1 Injury

Date Discovered 3/1/2013

Discovered by Injured Employee informed supervisor

Previous Incident? Yes No

5
If yes, describe:

Select the Direct Cause from

2 0 over)
Falls on same level (Slip/trip/fall, tip
Drop-Down to the Right
Question Description

Corrective Actions - Direct

Causes & Causal Factors
Incident Description / Detail

What exactly happened? Employee was picking up carton of product (35 Lbs.) from floor and placed on top of pallet

Where did it happen? In the Shipping Prep area

Who was involved? Only the injured employee

How did it happen? Employee lifted a box weighing 35 lbs.

When did it happen? Early afternoon, just after lunch around 1pm.

Why did it happen? Object was too heavy to lift from floor level. 25 lbs. is the limit for objects below the knees.

3 Nr. Interim Containment Plan (Immediate/Emergency Actions) Responsibility Due Date Status 6
1 Employee's Supervisor informed all in the area of the injury and reminded them to lift safely Joe Supervisor 3/1/2013
Contain

Take Preventive Measures

3

4a Man Machine Material

for Root Causes

Employee did not use The materials exceed
safe lifting practices safe floor level weights
Problem:
Cause & Effect (Fishbone)

Employee
Back Injury
7
Communication

Workplace design
required floor level lifting Floor level lifting

8
Method Management Environment
Verifica
Closur

tion
e
 4b 5 Why - Apply the most probable Causal Factors (s) of the Cause & Effect (Fishbone) Exercise

MATERIAL/METHOD/ENVIRONMENT)
RCA - 5 Why (Simply ask 'Why' to the identified
(MAN/MACHINE/MATERIAL/METHOD/MANA
(MAN) Employee did not use safe lifting Shipping Prep process requires
1 2 3 GEMENT/ENVIRONMENT)
Causal Factor until you get to Root Cause

practices employees to lift packages from floor

Why? level

Why?

Why?
Employee know the weight exceed limits but
Boxes are placed on the floor
does this job all the time
Why?

Why?

Why?
previous suggestions to change this after Work area was never evaluated for
ergo training did not get results ergonomic risk factors
Why?

Why?

Why?
Supervisor felt no changes would be This area was missed as part of the risk
forthcoming assessment
Why?

Why?

Why?
History of "no time available" for area re-
N/A
design.

Inadequate Engineering and/or design -

Why?

Why?

Why?
Inadequate Motivation: improper
inadequate evaluation of change and Insert Root Cause Here
supervisor example.
loss(risk) exposure.
SOP

SOP

SOP
Management Accountability Risk Assessment

5 Choose and Verify Corrective Actions for Direct Causes & Causal Factors (i.e. Replace broken ladder, train employee etc.)

Nr. Describe Corrective Action Here Responsibility End Date Status

Get the boxed off the floor so lifting occurs above the knees or lighted the boxes to below 25
1 Joe Supervisor 3/15/2013
lbs.
2 Update the risk assessment in place for this task in the shipping receiving department Joe Supervisor 3/31/2013
Corrective Actions - Direct
Causes & Causal Factors

9 star

6 Nr. Take Preventive Measures to Address Root Causes Identified from 5 Why star End Date Status

Review and Modify the Risk Assessment Process to ensure that Ergonomic risk factors are adequately
1 S&E Lead 3/31/2013
considered
Review and modify the supervisor safety performance metrics to ensure that ongoing improvements are
2 Management 3/31/2013
Take Preventive Measures

part of their job expectations / scorecard / monthly metrics

3
for Root Causes

10

7 Communication - Sharing of Lessons Learned - Do any of the corrective/Preventive actions listed above apply to other processes or systems?

If Yes, Describe Actions to Ensure Proper Sharing/Communication Responsibility End Date

Communication

Communicated the lessons learned with other sites in the region and allow regional S&E lead to determine if it
1 should be shared to all Mondelez locations
S&E Lead 4/31/13

2
If No, provide justification for non-necessity:

8 Closure Verifrication - Once the Corrective Actions have been verified, Close the Analysis and Congratulate the Team:
Verifica

Final Closure Date: (date all action items above are closed) Closed By:
Closur

tion
e

4/31/13 Team leader