RCA ID #: INCIDENT DATE: REPORT DATE:

Transcription

1 RCA ID #: INCIDENT DATE: REPORT DATE: PROJECT NAME/ ADDRESS NUMBER: LOCATION (CITY/ST): RCA TEAM MEMBERS Please identify standing in RCA - i.e.: LOB Mgr., CM, Safety, GF, Supv, Injured Employee (INJ), witness, etc. INCIDENT CATEGORY NEAR MISS INJURY/ILLNESS CRANE/RIGGING OTHER: VEHICLE INCIDENT PROPERTY DAMAGE MOBILE EQUIPMENT DESCRIBE: PRECISE DETAILS OF LOCATION: TIME OF INCIDENT: TIME ON DUTY WHEN INCIDENT OCCURRED: HOURS DAYS NUMBER OF PEOPLE DIRECTLY INVOLVED: NUMBER OF WITNESSES (not directly involved): INFORMATION ON EMPLOYEES DIRECTLY INVOLVED NAME JOB TITLE/POSITION YEARS OF EXPERIENCE YEARS OF EXPERIENCE IN TASK PERFORMED INCIDENT DESCRIPTION (Facts only; no assumptions, opinions, conclusions or recommendations) SITE CONDITIONS IN IMMEDIATE AREA (If pertinent):

2 IF INJURY/ILLNESS, DESCRIBE AFFECTED BODY PART: HEAD SHOULDER HAND/FINGERS EYE BACK KNEE FACE TORSO (includes abdomen) LEG/FOOT (includes ankle) NECK ARM (includes elbow) OTHER (specify) ACTIVITY TAKING PLACE THAT AFFECTED INCIDENT: On ladder Using power tools Crane/rigging operations On stairs Using hand tools Overhead work Walking Operating equipment Clean-up activity Lifting Working at heights Driving vehicle Carrying Handling materials Electrical hazard exposure Stored energy exposure (specify/describe) WHY WAS THIS ACTIVITY TAKING PLACE? WERE THERE ANY FACTORS ASSOCIATED WITH EQUIPMENT AND LAYOUT? (If yes, explain) WERE THERE CONFLICTING WORK OR TIME PRESSURES? (If yes, explain) IS THERE ANY OTHER INFORMATION THAT MAY HAVE HAD AN IMPACT ON THIS INCIDENT? (If yes, explain) CONTRACT TYPE: N/A T&M Hard Bid Target Price WAS SUPERVISOR WORKING WITH CREW AT TIME OF OCCURRENCE? (If not, explain)

3 PROCEDURES IN EFFECT DURING WORK ACTIVITY: (provide a brief explanation for any selection) JSA - Task Package Plan Routine Procedure Permits (Hot Work, Confined Space, etc.) Lift Plan (Cranes ETC.) POSSIBLE CONTRIBUTING FACTORS (provide brief explanation for any selection) Hurrying Lack of attention Improper use of tools Communication Equipment failure Housekeeping Job knowledge Deviation from normal procedure Fatigue or other physical factor Equipment design PPE Cramped work area Weather Area conditions (lighting, access, etc.) Preventive maintenance Hazard not identified/recognized Lack of training

4 WHAT HAPPENED? TEAM CONCLUSIONS Synopsis of incident, root causes, contributing factors, etc. WHY DID IT HAPPEN? CONCLUSION:

5 RCA ACTION ITEM AND FOLLOW UP LOG (Must be updated as status changes) RCA ID #: PROJECT NAME/NO: INCIDENT DATE: INCIDENT DESCRIPTION: IDENTIFIED ROOT CAUSES ASSOCIATED ACCIDENT FREE SYSTEMS 1 5 Leadership Planning 2 6 Employee Involvement Training 3 7 Effective Solutions Assessments/Inspections 4 8 NO Effective Solution LEVEL (0-3)* COMPLETED RESPONSIBLE PARTY STATUS (Include any info indicating effectiveness) DATE CLOSED *Level of corrective action: 1 = Meeting, stand down, gang box, etc. reminding people of what they already know/should know. definitive preventive action. 2 = One time action at the project level that ensures that this specific incident will not recur. 3 = Action taken at the project or Management Team level that requires a change in policy, prevents recurrence, and is measurable. or Serious Near Miss, Employee Clinic or ER Visit.