Action Form - Accident/incident Analysis Page 2
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1
2Contributing factors example
Leaking water
Drain was plugged,
No formal written
No management
Employee slipped
Water on
WHY
WHY
WHY
WHY
WHY
cooler, water wasn’t
machine wasn’t
maintenance
review of
and fell in the hallway
the floor
cleaned up
serviced
schedule
systems/policies
Surface causes
Root cause
I
dentify
Use the diagram
contributing factors
above as an
example.
Every accident/incident is
caused by a set of contributing
Surface cause:
factors. These factors
unsafe behaviors
and hazardous
represent the surface or root
conditions.
causes that led to the event.
The goal is to identify these
Root cause:
by analyzing how/why each
underlying
problems
consecutive event happened.
with policies/
procedures.
O
Engineering controls:
rganize
Use guarding, less
possible solutions
hazardous material
or a different design
Once the surface and root
to remove/reduce the
causes have been determined,
Management controls:
hazard.
you are ready to identify
possible solutions. These
Use work practices,
scheduling, or job
should be prioritized based
rotations to remove/
on their level of effectiveness.
Personal protective equipment (PPE):
reduce the exposure.
Remember to list multiple
solutions.
Place a barrier, such as
safety glasses, gloves,
ear plugs, between
employee and hazard.
N
ote corrective measures
Report your findings to
Your recommendations
Identify who will
Remember to keep
The last ACTION step is to
members of management
should be relevant and
be responsible for
accident reports on
use your notes from the steps
who have the authority
concise.
file for record keeping
completing the action
above to complete this form.
to act.
purposes.
items on your list.
How will you correct the issues addressed in the boxes above?
Person assigned: Completion date:
Supervisor/prepared by: __________________________________
Date: ________________
Copy: Safety Committee, Management Team,
Owner/President
Employee: _____________________________________________
Date: ________________
This is only an accident/incident analysis form. You will need to complete the workers’ compensation clam form (801) if the injury required medical treatment
beyond first aid. There are also other Oregon record keeping requirements for recording and reporting work-related fatalities, injuries, and illnesses.
Please reference for additional information on these requirements.
S924 SAIF Corporation 10/11
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Parent category: Business